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Sarubbi C, Abowali H, Varga C, Landau H. Treatment of AL amyloidosis in the era of novel immune and cellular therapies. Front Oncol 2024; 14:1425521. [PMID: 39007104 PMCID: PMC11239377 DOI: 10.3389/fonc.2024.1425521] [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: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 07/16/2024] Open
Abstract
Light chain (AL) amyloidosis is a plasma cell disorder distinguished from multiple myeloma (MM) by the degree of organ involvement due to tissue deposition of misfolded proteins. Treatments for AL amyloidosis have largely been borrowed from those developed for patients with MM. High-dose chemotherapy followed by autologous stem cell transplant (ASCT) has historically been associated with the best outcomes. The recent incorporation of daratumumab into up front therapy represents a significant advance and has changed the treatment paradigm, calling into question the role of ASCT. The development of very active novel immune and cellular therapies, specifically B cell maturation antigen (BCMA)-directed therapies, has similarly been transformative for patients with MM and is now being studied in patients with AL amyloidosis. These include chimeric antigen receptor (CAR) T cells, bispecific antibodies, and antibody drug conjugates. Although limited, preliminary data in patients with relapsed and refractory AL amyloidosis are showing promising results, and it is expected that the treatment landscape for AL amyloidosis will continue to evolve. Particular attention to safety, potential for organ recovery, and quality of life will be important when evaluating new treatments and/or treatment paradigms.
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Affiliation(s)
- Caitlin Sarubbi
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, United States
| | - Hesham Abowali
- Department of Hematology/Oncology, Brookdale University Medical Center, Brooklyn, NY, United States
| | - Cindy Varga
- Department of Hematology, Levine Cancer Institute Atrium Health, Charlotte, NC, United States
| | - Heather Landau
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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2
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Trikannad AK, Shrestha A, Vellanki S, Cheema HI, Patel TH, Bachu R, Sharma S, Jeffus SK, Thanendrarajan S. Amyloid Light-Chain (AL) Amyloidosis of the Trachea Associated With an Indolent B-cell Neoplasm. Cureus 2024; 16:e53074. [PMID: 38414681 PMCID: PMC10896678 DOI: 10.7759/cureus.53074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2024] [Indexed: 02/29/2024] Open
Abstract
We report the case of a 66-year-old woman who was diagnosed with localized tracheal amyloid light-chain (AL) amyloidosis caused by an underlying B-cell neoplasm. The diagnosis was confirmed through subsequent bronchoscopy and biopsies; however, she experienced a challenging episode of hypoxic respiratory failure that required intervention. Repeat bronchoscopies showed persistent subglottic stenosis and tracheobronchomalacia, which led to tracheal debulking surgery and additional interventions. The patient's treatment began with rituximab, zanubrutinib, and dexamethasone with outpatient follow-up. The rarity of tracheobronchial amyloidosis and its connection to B-cell malignancies are highlighted, emphasizing the challenges in diagnosis and the importance of tailored treatment strategies. The patient's clinical course, characterized by atypical respiratory symptoms, delayed diagnosis, and an evolving treatment approach, underscores the complexities of managing such a rare and intricate case.
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Affiliation(s)
- Anup Kumar Trikannad
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Asis Shrestha
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Sruthi Vellanki
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Hira I Cheema
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tanvi H Patel
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Ramya Bachu
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Shobhit Sharma
- Radiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Susanne K Jeffus
- Pathology, University of Arkansas for Medical Sciences, Little Rock, USA
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3
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Alnasser SM, Alharbi KS, Almutairy AF, Almutairi SM, Alolayan AM. Autologous Stem Cell Transplant in Hodgkin's and Non-Hodgkin's Lymphoma, Multiple Myeloma, and AL Amyloidosis. Cells 2023; 12:2855. [PMID: 38132175 PMCID: PMC10741865 DOI: 10.3390/cells12242855] [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: 11/12/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Human body cells are stem cell (SC) derivatives originating from bone marrow. Their special characteristics include their capacity to support the formation and self-repair of the cells. Cancer cells multiply uncontrollably and invade healthy tissues, making stem cell transplants a viable option for cancer patients undergoing high-dose chemotherapy (HDC). When chemotherapy is used at very high doses to eradicate all cancer cells from aggressive tumors, blood-forming cells and leukocytes are either completely or partially destroyed. Autologous stem cell transplantation (ASCT) is necessary for patients in those circumstances. The patients who undergo autologous transplants receive their own stem cells (SCs). The transplanted stem cells first come into contact with the bone marrow and then undergo engraftment, before differentiating into blood cells. ASCT is one of the most significant and innovative strategies for treating diseases. Here we focus on the treatment of Hodgkin's lymphoma, non-Hodgkin's lymphoma, multiple myeloma, and AL amyloidosis, using ASCT. This review provides a comprehensive picture of the effectiveness and the safety of ASCT as a therapeutic approach for these diseases, based on the currently available evidence.
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Affiliation(s)
- Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Khalid Saad Alharbi
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Ali F. Almutairy
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
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4
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Kastritis E, Misra A, Gurskyte L, Kroi F, Verhoek A, Vermeulen J, Ammann E, Lam A, Cote S, Wechalekar AD. Assessing the prognostic utility of hematologic response for overall survival in patients with newly diagnosed AL amyloidosis: results of a meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2157581. [PMID: 36607151 DOI: 10.1080/16078454.2022.2157581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Amyloid light-chain (AL) amyloidosis is a rare disease characterized by amyloid fibril deposits made up of toxic light chains causing progressive organ dysfunction and death. Recent studies suggest that hematologic response may be an important prognostic indicator of overall survival (OS) in AL amyloidosis. The aim of this study was to evaluate the trial-level association between hematologic complete response (CR) or very good partial response or better (≥ VGPR) and OS in newly diagnosed patients. METHODS Studies were identified via systematic literature review. Pooled effect estimates were generated by a random-effects model. RESULTS Nine observational studies reporting hematologic CR or ≥VGPR and OS hazard ratios (HRs) were included in the meta-analysis. Achieving hematologic CR was associated with improved OS (HR, 0.21; 95% confidence interval [CI] 0.13-0.34). Achieving ≥ VGPR was also associated with improved OS (HR 0.21; 95% CI 0.17-0.26). Results of a sensitivity analysis excluding one outlier study revealed no heterogeneity and a better overall HR estimate. Potential limitations of this meta-analysis include the small number of eligible studies (consistent with the rarity of the disease) and inconsistencies in reporting of results. CONCLUSIONS Overall, our findings support the use of deep hematologic response (CR or ≥VGPR) as a clinical trial endpoint in newly diagnosed AL amyloidosis. This study provides evidence that early hematologic response is a strong patient-level surrogate for long-term OS in patients with AL amyloidosis receiving frontline therapy. Structured data collection of depth of response in future trials will further strengthen these observations.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | - Eric Ammann
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Annette Lam
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Sarah Cote
- Janssen Global Services, LLC, Raritan, NJ, USA
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5
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Chakraborty R, Milani P, Palladini G, Gertz M. Role of autologous haematopoietic cell transplantation in the treatment of systemic light chain amyloidosis in the era of anti-CD38 monoclonal antibodies. Lancet Haematol 2023; 10:e936-e940. [PMID: 37802087 DOI: 10.1016/s2352-3026(23)00175-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 10/08/2023]
Abstract
The primary goal of the initial treatment in systemic light chain amyloidosis is to obtain a rapid and profound haematological response as safely as possible, coupled with supportive care by a multidisciplinary team. The treatment landscape has evolved with the introduction of highly effective therapies targeting the plasma cell clones, which can attain high rates of haematological complete response with minimal treatment-related morbidity and mortality. Consequently, the role of high-dose melphalan followed by autologous haematopoietic cell transplantation (HDM-AHCT) is being analysed, particularly considering the absence of randomised controlled trial data supporting its superiority over standard-dose therapies in systemic light chain amyloidosis treatment. In this Viewpoint, we will explore the role of HDM-AHCT in the management of patients with systemic light chain amyloidosis who are eligible for transplantation, and the unresolved questions surrounding HDM-AHCT use as both front-line and salvage therapy.
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Affiliation(s)
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Department of Molecular Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Department of Molecular Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Morie Gertz
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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Bar N, Firestone RS, Usmani SZ. Aiming for the cure in myeloma: Putting our best foot forward. Blood Rev 2023; 62:101116. [PMID: 37596172 DOI: 10.1016/j.blre.2023.101116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/20/2023]
Abstract
Frontline therapy for multiple myeloma (MM) is evolving to include novel combinations that can achieve unprecedented deep response rates. Several treatment strategies exist, varying in induction regimen composition, use of transplant and or consolidation and maintenance. In this sea of different treatment permutations, the overarching theme is the powerful prognostic factors of disease risk and achievement of minimal residual disease (MRD) negativity. MM has significant inter-patient variability that requires treatment to be individualized. Risk-adapted and response-adapted strategies which are increasingly being explored to define the extent and duration of therapy, and eventually aim for functional curability. In addition, with T-cell redirection therapies rapidly revolutionizing myeloma treatments, the current standard of care for myeloma will change. This review analyzes the current relevant literature in upfront therapy for fit myeloma patients and provides suggestions for treatment approach while novel clinical trials are maturing.
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Affiliation(s)
- Noffar Bar
- Section of Hematology, Department of Internal Medicine, Yale School of Medicine University, New Haven, CT, USA.
| | - Ross S Firestone
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Saad Z Usmani
- Multiple Myeloma Service, Department of medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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7
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Iijima T, Sawa N, Oba Y, Ikuma D, Mizuno H, Yamanouchi M, Suwabe T, Wake A, Kono K, Ubara Y, Ohashi K. Cardiac and renal AL amyloidosis controlled by autologous stem cell transplantation for 17 years accompanying late onset atrial fibrillation and complete atrioventricular block. CEN Case Rep 2023; 12:362-367. [PMID: 36795309 PMCID: PMC10620357 DOI: 10.1007/s13730-023-00777-8] [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: 08/20/2022] [Accepted: 02/06/2023] [Indexed: 02/17/2023] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare hematologic disease that may involve multiple organs. Amongst the organs, cardiac involvement causes the greatest concern as its treatment is challenging. Diastolic dysfunction rapidly progresses to decompensated heart failure, pulseless electrical activity, and atrial standstill due to electro-mechanical dissociation resulting in death. High-dose melphalan plus autologous stem cell transplantation (HDM-ASCT) is the most radical treatment but its risk is very high and thus only less than 20% of patients can receive this therapy under criteria that can suppress treatment-related mortality. In substantial proportion of patients, levels of M protein remain elevated, and organ response cannot be achieved. Moreover, relapse may occur, making prediction of treatment response and judgement of disease eradication very difficult. Herein we report a case of AL amyloidosis who was treated with HDM-ASCT, resulting in preserved cardiac function and resolution of proteinuria for more than 17 years after HDM-ASCT ensuing atrial fibrillation and complete atrioventricular block required management by catheter ablation and pacemaker implantation 10 years and 12 years after transplantation, respectively.
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Affiliation(s)
- Takashi Iijima
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan.
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
| | - Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital Kajigaya, Kawasaki, Japan
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1, Kajigaya, Takatsu, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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8
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Suárez EU. Hottest topics in hematopoietic stem cell transplantation: a summary from the 8th International Transplant and Cellular Therapy Course. Clin Hematol Int 2023; 5:89034. [PMID: 37869470 PMCID: PMC10588818 DOI: 10.46989/001c.89034] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Edwin U Suárez
- Hematology Department Fundación Jiménez Díaz University Hospital, Madrid, Spain
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9
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Morfino P, Aimo A, Castiglione V, Chianca M, Vergaro G, Cipolla CM, Fedele A, Emdin M, Fabiani I, Cardinale D. Cardiovascular toxicity from therapies for light chain amyloidosis. Front Cardiovasc Med 2023; 10:1212983. [PMID: 37476571 PMCID: PMC10354454 DOI: 10.3389/fcvm.2023.1212983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/23/2023] [Indexed: 07/22/2023] Open
Abstract
Amyloid light-chain (AL) amyloidosis is a hematological disorder characterized by abnormal proliferation of a plasma cell clone producing monoclonal free light chains that misfold and aggregate into insoluble fibrils in various tissues. Cardiac involvement is a common feature leading to restrictive cardiomyopathy and poor prognosis. Current first-line treatments aim at achieving hematological response by targeting the plasma cell clones, and these have been adapted from multiple myeloma therapy. Patients with AL amyloidosis often exhibit multiorgan involvement, making them susceptible to cancer therapy-related cardiovascular toxicity. Managing AL amyloidosis is a complex issue that requires enhanced knowledge of the cardio-oncological implications of hematological treatments. Future research should focus on implementing and validating primary and secondary prevention strategies and understanding the biochemical basis of oncological therapy-related damage to mitigate cardiovascular toxicity.
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Affiliation(s)
- Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michela Chianca
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Carlo Maria Cipolla
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Antonella Fedele
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Daniela Cardinale
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
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10
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Jerome S, Farrell MB, Warren J, Embry-Dierson M, Schockling EJ. Cardiac Amyloidosis Imaging, Part 3: Interpretation, Diagnosis, and Treatment. J Nucl Med Technol 2023; 51:102-116. [PMID: 37268322 DOI: 10.2967/jnmt.123.265492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/10/2023] [Indexed: 06/04/2023] Open
Abstract
Cardiac amyloidosis was thought to be rare, undiagnosable, and incurable. However, recently it has been discovered to be common, diagnosable, and treatable. This knowledge has led to a resurgence in nuclear imaging with 99mTc-pyrophosphate-a scan once believed to be extinct-to identify cardiac amyloidosis, particularly in patients with heart failure but preserved ejection fraction. The renewed interest in 99mTc-pyrophosphate imaging has compelled technologists and physicians to reacquaint themselves with the procedure. Although 99mTc-pyrophosphate imaging is relatively simple, interpretation and diagnostic accuracy require an in-depth knowledge of amyloidosis etiology, clinical manifestations, disease progression, and treatment. Diagnosing cardiac amyloidosis is complicated because typical signs and symptoms are nonspecific and usually attributed to other cardiac disorders. In addition, physicians must be able to differentiate between monoclonal immunoglobulin light-chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). Several clinical and noninvasive diagnostic imaging (echocardiography and cardiac MRI) red flags have been identified that suggest a patient may have cardiac amyloidosis. The intent of these red flags is to raise physician suspicion of cardiac amyloidosis and guide a series of steps (a diagnostic algorithm) for narrowing down and diagnosing the specific amyloid type. One element in the diagnostic algorithm is to identify monoclonal proteins indicative of AL. Monoclonal proteins are detected by serum or urine immunofixation electrophoresis and serum free light-chain assay. Another element is identifying and grading cardiac amyloid deposition using 99mTc-pyrophosphate imaging. When monoclonal proteins are present and the 99mTc-pyrophosphate scan is positive, the patient should be further evaluated for cardiac AL. The absence of monoclonal proteins and a positive 99mTc-pyrophosphate scan is diagnostic for cardiac ATTR. Patients with cardiac ATTR need to undergo genetic testing to differentiate between wild-type ATTR and variant ATTR. This article is the third in a 3-part series in this issue of the Journal of Nuclear Medicine Technology Part 1 reviewed amyloidosis etiology and outlined 99mTc-pyrophosphate study acquisition. Part 2 described 99mTc-pyrophosphate image quantification and protocol technical considerations. This article discusses scan interpretation along with cardiac amyloidosis diagnosis and treatment.
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Affiliation(s)
- Scott Jerome
- University of Maryland School of Medicine, Westminster, Maryland
| | | | | | | | - Eric J Schockling
- Outpatient Cardiovascular Diagnostics, Norton Healthcare, LLC, Louisville, Kentucky
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11
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Dima D, Mazzoni S, Anwer F, Khouri J, Samaras C, Valent J, Williams L. Diagnostic and Treatment Strategies for AL Amyloidosis in an Era of Therapeutic Innovation. JCO Oncol Pract 2023; 19:265-275. [PMID: 36854070 DOI: 10.1200/op.22.00396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Despite significant progress and improving outcomes in the management of plasma cell disorders, AL amyloidosis remains diagnostically and therapeutically challenging for clinicians across practice settings. There is, however, a reason for optimism with the advent of new combination therapy approaches and novel targets offering the promise of improvement in end organ function, survival, and quality of life. This review offers a clinically applicable overview of an approach to diagnosis, risk stratification, and clinical management of AL amyloidosis in an era of rapid therapeutic innovation.
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Affiliation(s)
- Danai Dima
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Sandra Mazzoni
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Faiz Anwer
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Jack Khouri
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | | | - Jason Valent
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Louis Williams
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
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12
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Diagnosis and Treatment of AL Amyloidosis. Drugs 2023; 83:203-216. [PMID: 36652193 DOI: 10.1007/s40265-022-01830-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Systemic light chain (AL) amyloidosis is caused by an usually small B cell clone that produces a toxic light chain forming amyloid deposits in tissue. The heart and kidney are the major organs affected, but all others, with the exception of the CNS, can be involved. The disease is rapidly progressive, and it is still diagnosed late. Screening programs in patients followed by hematologists for plasma cell dyscrasias should be considered. The diagnosis requires demonstration in a tissue biopsy of amyloid deposits formed by immunoglobulin light chains. The workup of patients with AL amyloidosis requires adequate technology and expertise, and patients should be referred to specialized centers whenever possible. Stagings are based on cardiac and renal biomarkers and guides the choice of treatment. The combination of daratumumab, cyclophosphamide, bortezomib and dexamethasone (dara-CyBorD) is the current standard of care. Autologous stem cell transplant is performed in eligible patients, especially those who do not attain a satisfactory response to dara-CyBorD. Passive immunotherapy targeting the amyloid deposits combined with chemo-/immune-therapy targeting the amyloid clone is currently being tested in controlled clinical trials. Response to therapy is assessed based on validated criteria. Profound hematologic response is the early goal of treatment and should be accompanied over time by deepening organ response. Many relapsed/refractory patients are also treated with daratumumab combination, but novel regimens will be needed to rescue daratumumab-exposed subjects. Immunomodulatory drugs are the current cornerstone of rescue therapy, while immunotherapy targeting B-cell maturation antigen and inhibitors of Bcl-2 are promising alternatives.
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13
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Single Center Experience of Autologous Stem Cell Transplantation in Patients with Systemic Light Chain Amyloidosis in Korea. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:97-103. [PMID: 36464620 DOI: 10.1016/j.clml.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Systemic light chains is the most common systemic amyloidosis. In patients with AL amyloidosis, the prognosis is influenced by the extent of organ damage, especially cardiac involvement. Autologous stem cell transplantation (ASCT) is a highly effective treatment for AL amyloidosis for selective patient METHODS: One hundred patients treated with ASCT for AL amyloidosis were reviewed in the Samsung Medical Center amyloidosis cohort. The cardiac, renal, and hematologic response was analyzed, and survival results compared based on organ involvement and hematologic response. RESULTS The most common involved organ was kidney (n = 62) followed by heart (n = 50). The organ response rate was 44.0% and 37.1% in the patients with cardiac and renal involvement, respectively. In hematologic response, overall response rate (ORR) was 79.0%, including 48.0% complete response (CR). Median overall survival (OS) in patients with and without hematologic CR were not reached and 64.2 months (95% CI, 19.5 to 109.0), respectively (P < .001). The survival rate was not significantly different between patients with or without cardiac or renal involvement. Treatment-related mortality (TRM) in 30 days and 100 days was 2.0% and 3.0%, respectively. CONCLUSIONS ASCT is an effective treatment option for eligible patients with AL amyloidosis. Achieving hematologic CR is essential for long-term survival.
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Kitchlu A, Chan CT, Jhaveri KD, Delgado D, Tam P. Amyloidoses in Onco-Nephrology Practice: A Multidisciplinary Case-Based Conference Report. Can J Kidney Health Dis 2023; 10:20543581231165711. [PMID: 37101848 PMCID: PMC10123889 DOI: 10.1177/20543581231165711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/09/2023] [Indexed: 04/28/2023] Open
Abstract
Introduction and Objective Amyloidoses are a heterogeneous group of disorders resulting from deposition of amyloid fibrils into extracellular tissues. While the kidneys are one of the most frequent sites of amyloid deposition, amyloid deposits can also affect a wide range of organ systems, including the heart, liver, gastrointestinal tract, and peripheral nerves. The prognosis of amyloidosis, especially with cardiac involvement, remains poor; however, a collaborative approach applying new tools for diagnosis and management may improve outcomes. In September 2021, the Canadian Onco-Nephrology Interest Group hosted a symposium to discuss diagnostic challenges and recent advances in the management of amyloidosis from the perspectives of the nephrologist, cardiologist, and onco-hematologist. Methods and Sources of Information Through structured presentations, the group discussed a series of cases highlighting the varied clinical presentations of amyloidoses affecting the kidney and heart. Expert opinions, clinical trial findings, and publication summaries were used to illustrate patient-related and treatment-related considerations in the diagnosis and management of amyloidoses. Key findings (1) Overview of the clinical presentation of amyloidoses and the role of specialists in performing timely and accurate diagnostic workup; (2) review of best practices for multidisciplinary management of amyloidosis, including prognostic variables and determinants of treatment response; and (3) update on new and emerging treatments in the management of light chain and amyloid transthyretin amyloidoses. Limitations This conference featured multidisciplinary discussion of cases, and learning points reflect the assessments by the involved experts/authors. Implications Identification and management of amyloidoses can be facilitated with a multidisciplinary approach and higher index of suspicion from cardiologists, nephrologists, and hemato-oncologists. Increased awareness of clinical presentations and diagnostic algorithms for amyloidosis subtyping will lead to more timely interventions and improved clinical outcomes.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, ON, Canada
- Abhijat Kitchlu, Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, 200 Elizabeth St, 8N-842, Toronto, ON M5G 2C4, Canada.
| | - Christopher T. Chan
- Department of Medicine, Division of Nephrology, University Health Network, University of Toronto, ON, Canada
| | - Kenar D. Jhaveri
- The Glomerular Disease Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Diego Delgado
- Division of Cardiology, Heart Failure and Transplant Program, University Health Network, Toronto General Hospital, ON, Canada
| | - Paul Tam
- Division of Nephrology, The Scarborough Hospital, Toronto, ON, Canada
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15
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Bou Zerdan M, George TI, Bunting ST, Chaulagain CP. Recent Advances in the Treatment and Supportive Care of POEMS Syndrome. J Clin Med 2022; 11:jcm11237011. [PMID: 36498588 PMCID: PMC9741379 DOI: 10.3390/jcm11237011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/13/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
POEMS is a rare clonal plasma cell disorder characterized by multi-systemic features that include demyelinating peripheral neuropathy, organomegaly, endocrinopathy, presence of monoclonal proteins (M-protein), and skin changes. Even though the pathophysiology is poorly understood, recent studies suggest that both clonal and polyclonal plasmacytosis leading to the production of pro-inflammatory cytokines and angiogenic mediators play the central role. These mediators including vascular endothelial growth factor (VEGF) are the driving forces of the syndrome. The diagnosis of POEMS is not always straight forward and often the diagnosis is delayed. It is based on fulfilling mandatory criteria of polyradiculoneuropathy and monoclonal protein and the presence of one major criterion (Castleman disease, sclerotic bone lesions, or elevated VEGF), and at least one minor criterion. Due to the presence of neuropathy, it can be confused with chronic inflammatory demyelinating polyradiculopathy (CIDP), and if thrombocytosis and splenomegaly are present, it can be confused with myeloproliferative neoplasms. Due to the rarity of the syndrome, clear guidelines for treatment are still lacking. Immediate treatment targeting the underlying plasma cell proliferation results in a dramatic response in most patients. The key is early diagnosis and immediate anti-plasma cell directed therapy for the best clinical outcomes. For patients with disseminated disease as defined by bone marrow involvement or more than three osteosclerotic bone lesions, high-dose chemotherapy with autologous hematopoietic stem cell transplant (ASCT) yields durable responses and is the preferred treatment in eligible patients. For patients with localized bony disease, radiotherapy has proven to be very effective. Lenalidomide and dexamethasone is a proven therapy in patients ineligible for ASCT. In this review article, we tackle the diagnostic approach and discuss the latest treatment modalities of this rare debilitating disease.
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Affiliation(s)
- Maroun Bou Zerdan
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
- Department of Internal Medicine, SUNY Upstate Medical University Hospital, Syracuse, NY 13210, USA
| | - Tracy I. George
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
| | - Silvia Tse Bunting
- Division of Hematopathology and Flow Cytometry Laboratory, Department of Pathology, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
| | - Chakra P. Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida 2950, Weston, FL 33331, USA
- Correspondence: ; Tel.: +1-954-659-5840; Fax: +1-954-659-5810
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16
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Ueno H, Douhara A, Osaki Y, Koizumi A, Yorioka N, Ueda S, Tsutsumi M, Yoshiji H. Liver Biopsy-confirmed Primary Hepatic Amyloidosis with Only Jaundice As the Initial Symptom: An Autopsy Case Report. Intern Med 2022; 61:2877-2881. [PMID: 35228432 PMCID: PMC9593147 DOI: 10.2169/internalmedicine.9189-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Amyloidosis causes various symptoms in many organs of the body, but amyloidosis that presents with liver damage alone has never been reported. We treated an 83-year-old man with amyloidosis who presented with liver damage alone. The liver damage in this patient was histologically proven to be liver amyloidosis. The administration of bortezomib and dexamethasone was not effective, so he rapidly died of liver failure. An aggressive liver biopsy should be considered when unexplained jaundice is observed.
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Affiliation(s)
- Hirotsugu Ueno
- Department of Gastroenterology, Saiseikai Chuwa Hospital, Japan
| | | | - Yui Osaki
- Department of Gastroenterology, Saiseikai Chuwa Hospital, Japan
| | | | | | - Shigehiko Ueda
- Department of Gastroenterology, Saiseikai Chuwa Hospital, Japan
| | | | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Japan
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17
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Iijima T, Sawa N, Nakayama Y, Oba Y, Ikuma D, Mizuno H, Yamanouchi M, Suwabe T, Wake A, Kono K, Hoshino J, Ubara Y, Ohashi K. Vincristine, Doxorubicin, and Dexamethasone Induction before Autologous Stem Cell Transplantation in Patients with AL Amyloidosis: A Retrospective Comparison with Frontline Stem Cell Transplantation. Intern Med 2022; 61:2853-2860. [PMID: 35228429 PMCID: PMC9593158 DOI: 10.2169/internalmedicine.9039-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective High-dose melphalan and autologous stem cell transplantation (ASCT) therapy for AL amyloidosis are now associated with reduced mortality based on the application of strict criteria. However, there is no long-term evidence concerning the performance of induction therapy with newer agents, such as bortezomib or daratumumab. Concerns regarding long-term relapse despite treatment with ASCT exist, and missing the opportunity to perform ASCT might occur if induction proves to not be efficacious and cardiac amyloidosis progression deprives the patients of a chance to receive ASCT. We herein report good amyloid control by vincristine, doxorubicin, and dexamethasone (VAD) induction therapy and argue the importance of induction therapy before ASCT. Methods We compared patients who underwent VAD induction and ASCT (VAD+ASCT) with patients who underwent frontline ASCT in our hospital. Patients A total of 26 patients with histologically proven AL amyloidosis were included (18 in the VAD+ASCT group and 8 in the frontline ASCT). Results In the VAD+ASCT group, the 10-year overall survival and renal response rates were 82% and 43%, respectively. The renal response rate at two years in the VAD+ASCT group was significantly better than that in the frontline ASCT group. Although there was no significant difference in the survival rates between the two groups, the time to next treatment or death was significantly better in the VAD+ASCT group than in the the frontline ASCT group. Acute kidney injury was the most frequent reason for failure to receive two courses of VAD, and early mortality was mainly due to gastrointestinal complications. Conclusion Considering that only those who underwent 2 courses of VAD experienced a 10-year renal response, induction therapy was deemed to be directly related to the long-term control of AL amyloidosis.
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Affiliation(s)
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yuki Nakayama
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Atsushi Wake
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
- Department of Hematology, Toranomon Hospital Kajigaya, Japan
- Department of Hematology, Toranomon Hospital, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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18
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Gustine JN, Staron A, Szalat R, Mendelson L, Joshi T, Ruberg FL, Siddiqi O, Gopal DM, Edwards CV, Havasi A, Kaku M, Lau KHV, Berk JL, Sloan JM, Sanchorawala V. Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: a 25-year longitudinal study. Am J Hematol 2022; 97:1189-1199. [PMID: 35731907 DOI: 10.1002/ajh.26641] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/07/2022]
Abstract
High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I >0.1 ng/mL, and serum creatinine >2.0 mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p<0.001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joshua N Gustine
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Raphael Szalat
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, 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.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Omar Siddiqi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Deepa M Gopal
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Camille V Edwards
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Michelle Kaku
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - K H Vincent Lau
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Pulmonology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, 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.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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19
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Molecular Mechanism of Pathogenesis and Treatment Strategies for AL Amyloidosis. Int J Mol Sci 2022; 23:ijms23116336. [PMID: 35683015 PMCID: PMC9181426 DOI: 10.3390/ijms23116336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/17/2022] Open
Abstract
In amyloid light-chain (AL) amyloidosis, small B-cell clones (mostly plasma cell clones) present in the bone marrow proliferate and secrete unstable monoclonal free light chains (FLCs), which form amyloid fibrils that deposit in the interstitial tissue, resulting in organ injury and dysfunction. AL amyloidosis progresses much faster than other types of amyloidosis, with a slight delay in diagnosis leading to a marked exacerbation of cardiomyopathy. In some cases, the resulting heart failure is so severe that chemotherapy cannot be administered, and death sometimes occurs within a few months. To date, many clinical studies have focused on therapeutics, especially chemotherapy, to treat this disease. Because it is necessary to promptly lower FLC, the causative protein of amyloid, to achieve a hematological response, various anticancer agents targeting neoplastic plasma cells are used for the treatment of this disease. In addition, many basic studies using human specimens to elucidate the pathophysiology of AL have been conducted. Gene mutations associated with AL, the characteristics of amyloidogenic LC, and the structural specificity of amyloid fibrils have been clarified. Regarding the mechanism of cellular and tissue damage, the mass effect due to amyloid deposition, as well as the toxicity of pre-fibrillar LC, is gradually being elucidated. This review outlines the pathogenesis and treatment strategies for AL amyloidosis with respect to its molecular mechanisms.
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20
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Sanchorawala V, Palladini G, Minnema MC, Jaccard A, Lee HC, Gibbs S, Mollee P, Venner C, Lu J, Schönland S, Gatt M, Suzuki K, Kim K, Cibeira MT, Beksac M, Libby E, Valent J, Hungria V, Wong SW, Rosenzweig M, Bumma N, Chauveau D, Gries KS, Fastenau J, Tran NP, Qin X, Vasey SY, Weiss BM, Vermeulen J, Ho KF, Merlini G, Comenzo RL, Kastritis E, Wechalekar AD. Health-related quality of life in patients with light chain amyloidosis treated with bortezomib, cyclophosphamide, and dexamethasone ± daratumumab: Results from the ANDROMEDA study. Am J Hematol 2022; 97:719-730. [PMID: 35293006 DOI: 10.1002/ajh.26536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 02/02/2022] [Accepted: 02/28/2022] [Indexed: 12/19/2022]
Abstract
In the phase 3 ANDROMEDA trial, patients treated with daratumumab, bortezomib, cyclophosphamide, and dexamethasone (D-VCd) had significantly higher rates of organ and hematologic response compared with patients who received VCd alone. Here, we present patient-reported outcomes (PROs) from the ANDROMEDA trial. PROs were assessed through cycle 6 using three standardized questionnaires. Treatment effect through cycle 6 was measured by a repeated-measures, mixed-effects model. The magnitude of changes in PROs versus baseline was generally low, but between-group differences favored the D-VCd group. Results were generally consistent irrespective of hematologic, cardiac, or renal responses. More patients in the D-VCd group experienced meaningful improvements in PROs; median time to improvement was more rapid in the D-VCd group versus the VCd group. After cycle 6, patients in the D-VCd group received daratumumab monotherapy and their PRO assessments continued, with improvements in health-related quality of life (HRQoL) reported through cycle 19. PROs of subgroups with renal and cardiac involvement were consistent with those of the intent-to-treat population. These results demonstrate that the previously reported clinical benefits of D-VCd were achieved without decrement to patients' HRQoL and provide support of D-VCd in patients with AL amyloidosis.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Department of Hematology Boston University School of Medicine and Boston Medical Center Boston Massachusetts USA
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Monique C. Minnema
- Department of Hematology University Medical Center Utrecht Utrecht Netherlands
| | - Arnaud Jaccard
- Service d'hématologie clinique et de thérapie cellulaire CHU de Limoges Limoges France
| | - Hans C. Lee
- Department of Lymphoma and Myeloma, Division of Cancer Medicine University of Texas, MD Anderson Cancer Center Houston Texas USA
| | - Simon Gibbs
- The Victorian and Tasmanian Amyloidosis Service, Department of Haematology Monash University Eastern Health Clinical School Box Hill Victoria Australia
| | - Peter Mollee
- Department of Hematology Princess Alexandra Hospital and University of Queensland Medical School Brisbane Queensland Australia
| | | | - Jin Lu
- Institute of Hematology Peking University People's Hospital Beijing China
| | - Stefan Schönland
- Amyloidosis Center Universitaetsklinikum Heidelberg Medizinische Klinik V Heidelberg Germany
| | - Moshe Gatt
- Hematology Department Hadassah Medical Center Jerusalem Israel
| | - Kenshi Suzuki
- Department of Hematology Japanese Red Cross Central Medical Center, Shibuya Tokyo Japan
| | - Kihyun Kim
- Department of Medicine Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul South Korea
| | - María Teresa Cibeira
- Amyloidosis and Myeloma Unit Hospital Clinic of Barcelona, IDIBAPS Barcelona Spain
| | - Meral Beksac
- Department of Hematology Ankara University Ankara Turkey
| | - Edward Libby
- Division of Medical Oncology, Department of Medicine University of Washington Seattle Washington USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Taussig Cancer Center Cleveland Clinic Cleveland Ohio USA
| | - Vania Hungria
- Department of Hematology Clinica São Germano São Paulo Brazil
| | - Sandy W. Wong
- UCSF Helen Diller Family Comprehensive Cancer Center University of California San Francisco California USA
| | - Michael Rosenzweig
- Department of Hematology and Hematopoietic Cell Transplantation, Judy and Bernard Briskin Center for Multiple Myeloma Research City of Hope Duarte California USA
| | - Naresh Bumma
- Division of Hematology The Ohio State University Comprehensive Cancer Center Columbus Ohio USA
| | - Dominique Chauveau
- Centre de Référence des Maladies Rénales Rares, Département de Néphrologie et Transplantation d'Organes CHU de Toulouse Toulouse France
| | | | - John Fastenau
- Janssen Research & Development, LLC Raritan New Jersey USA
| | - Nam Phuong Tran
- Janssen Research & Development, LLC Los Angeles California USA
| | - Xiang Qin
- Janssen Research & Development, LLC Spring House Pennsylvania USA
| | - Sandra Y. Vasey
- Janssen Research & Development, LLC Spring House Pennsylvania USA
| | - Brendan M. Weiss
- Janssen Research & Development, LLC Spring House Pennsylvania USA
| | | | | | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Raymond L. Comenzo
- Division of Hematology/Oncology, John C. Davis Myeloma and Amyloid Program Tufts Medical Center Boston Massachusetts USA
| | - Efstathios Kastritis
- Department of Clinical Therapeutics National and Kapodistrian University of Athens School of Medicine Athens Greece
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Indications for haematopoietic cell transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe, 2022. Bone Marrow Transplant 2022; 57:1217-1239. [PMID: 35589997 PMCID: PMC9119216 DOI: 10.1038/s41409-022-01691-w] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 12/17/2022]
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22
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Abdallah M, Sanchorawala V. Update on the Contemporary Treatment of Light Chain Amyloidosis Including Stem Cell Transplantation. Am J Med 2022; 135 Suppl 1:S30-S37. [PMID: 35081382 DOI: 10.1016/j.amjmed.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022]
Abstract
The management of immunoglobulin light chain (AL) amyloidosis is complex. Emerging data have shown promising results for several novel agents. We review the management of AL amyloidosis, including factors that determine transplant eligibility, treatment options for transplant-ineligible patients, and treatment options for relapsed/refractory AL amyloidosis. For carefully selected patients, high-dose melphalan and stem cell transplantation is recommended. Transplant eligibility criteria generally include biopsy-proven amyloidosis, evidence of a plasma cell dyscrasia, involvement of at least one major organ, and adequate performance status. For transplant-ineligible patients, bortezomib-based regimens are recommended, including: 1) bortezomib, oral melphalan, and dexamethasone (BMDex); 2) bortezomib, cyclophosphamide, and dexamethasone (CyBorD or VCd); and 3) subcutaneous daratumumab (DARA SC) and VCd. The latter option is based on a landmark trial that led to the first US Food and Drug Administration-approved therapy for AL amyloidosis. For relapsed/refractory disease, novel therapeutics including proteosome inhibitors, immunomodulatory agents, and monoclonal antibodies have shown promising results. In this review, we summarize data for various therapeutics in different clinical scenarios of AL amyloidosis.
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Affiliation(s)
- Maya Abdallah
- Section of Hematology/Oncology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Mass
| | - Vaishali Sanchorawala
- Section of Hematology/Oncology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Mass; Amyloidosis Center, Boston University School of Medicine, Boston, Mass.
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23
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Distinguishing Cardiac Amyloidosis and Hypertrophic Cardiomyopathy by Thickness and Myocardial Deformation of the Right Ventricle. Cardiol Res Pract 2022; 2022:4364279. [PMID: 35154823 PMCID: PMC8825671 DOI: 10.1155/2022/4364279] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives To compare right ventricular thickness (RVT) and deformation of cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) patients. Methods Sixty CA (mean age 58 ± 10 years; 33 males (55%)) and sixty HCM patients (mean age 55 ± 14 years; 27 males (45%)) were retrospectively enrolled. RVT, global radical peak strain (GRPS), global longitudinal peak strain (GLPS), and global circumferential peak stain (GCPS) were analyzed. To determine the cutoff values of the RVT and RV strain parameters for distinguishing CA from HCM, the areas under the receiver operating characteristic curve (AUCs) were analyzed. Results RVT of CA patients was significantly thicker than that of HCM patients (7.8 ± 2.1 vs 5.9 ± 1.3, p < 0.001). Moreover, significantly decreased RV-GRPS (12.1 ± 6.9 vs 23.5 ± 12.1, p < 0.001), RV-GCPS (−3.4 ± 2.2 vs −5.6 ± 3.5, p < 0.001), and RV-GLPS (−4.6 ± 2.3 vs −11.1 ± 4.9, p < 0.001) were observed in CA patients compared with HCM patients. RVT and RV strain demonstrate comparable diagnostic accuracy in differentiating CA from HCM. In particular, RV-GLPS combined with RVT showed the best performance for discriminating CA from HCM (AUC = 0.92, 95% CI: 0.85 to 0.96, p = 0.0001). Conclusions Right ventricular myocardial thickness and deformation of CA patients was more severe than HCM patients. RV-GLPS combined with RVT presents an excellent diagnostic performance in distinguishing CA and HCM.
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24
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Morozkina SN, Snetkov PP, Olekhnovich RO, Uspenskaya MV. Modern Approaches To Cardiovascular Amyloidosis Treatment. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Cardiovascular (cardiac) amyloidosis (CA) is a clinical pathology, usually of a geneticallymediated nature, initiated by the precipitation process of the insoluble fibrous protein with β-pleated sheet secondary structure. Such anomalous changes lead to the formation of amyloid fibrils, which may give rise to various forms of amyloidosis. Amyloid formation can be found in various organs and systems, such as cardiovascular system, central and peripheral nervous systems, liver, urinary tract, etc. CA is a rare degenerative disease resulting in congestive cardiac failure and heart arrhythmia with subsequent untimely death. Unfortunately, up to date, the choice of medications for treating amyloidosis is very limited. In this paper, we review clinically used pharmaceutical drugs for CA treatment, along with some delivery systems for such compounds.
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Molecular Mechanisms of Cardiac Amyloidosis. Int J Mol Sci 2021; 23:ijms23010025. [PMID: 35008444 PMCID: PMC8744761 DOI: 10.3390/ijms23010025] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/18/2021] [Accepted: 12/18/2021] [Indexed: 12/22/2022] Open
Abstract
Cardiac involvement has a profound effect on the prognosis of patients with systemic amyloidosis. Therapeutic methods for suppressing the production of causative proteins have been developed for ATTR amyloidosis and AL amyloidosis, which show cardiac involvement, and the prognosis has been improved. However, a method for removing deposited amyloid has not been established. Methods for reducing cytotoxicity caused by amyloid deposition and amyloid precursor protein to protect cardiovascular cells are also needed. In this review, we outline the molecular mechanisms and treatments of cardiac amyloidosis.
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Chandrashekar P, Desai AK, Trachtenberg BH. Targeted treatments of AL and ATTR amyloidosis. Heart Fail Rev 2021; 27:1587-1603. [PMID: 34783948 DOI: 10.1007/s10741-021-10180-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 12/22/2022]
Abstract
The therapeutic landscape for cardiac amyloidosis is rapidly evolving. In the last decade, our focus has shifted from dealing with the inevitable complications of continued extracellular infiltration of amyloid fibrils to earlier identification of these patients with prompt initiation of targeted therapy to prevent further deposition. Although much of the focus on novel targeted therapies is within the realm of transthyretin amyloidosis, light chain amyloidosis has benefited due to an overlap particularly in the final common pathway of fibrillogenesis and extraction of amyloid fibrils from the heart. Here, we review the targeted therapeutics for transthyretin and light chain amyloidosis. For transthyretin amyloidosis, the list of current and future therapeutics continues to evolve; and therefore, it is crucial to become familiar with the underlying mechanistic pathways of the disease. Although targeted therapeutic choices in AL amyloidosis are largely driven by the hematology team, the cardiac adverse effect profiles of these therapies, particularly in those with advanced amyloidosis, provide an opportunity for early recognition to prevent decompensation and can help inform recommendations regarding therapy changes when required.
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Affiliation(s)
- Pranav Chandrashekar
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Anish K Desai
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Barry H Trachtenberg
- Methodist DeBakey Heart and Vascular Center, Houston, TX, USA. .,Cardio-Oncology and Cardiac Amyloidosis Program, Advanced Heart Failure Fellowship Program, Methodist DeBakey Heart and Vascular Centers, J.C. Walter Transplant Center, Houston, USA.
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How the amyloid fibril has unraveled: lessons for nephrology. Kidney Int 2021; 101:663-665. [PMID: 34774557 DOI: 10.1016/j.kint.2021.10.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 10/28/2021] [Indexed: 11/21/2022]
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Bianchi G, Zhang Y, Comenzo RL. AL Amyloidosis: Current Chemotherapy and Immune Therapy Treatment Strategies: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:467-487. [PMID: 34729520 PMCID: PMC8543128 DOI: 10.1016/j.jaccao.2021.09.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/19/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is an incurable plasma cell disorder characterized by deposition of fibrils of misfolded immunoglobulin free light chains (FLC) in target organs, leading to failure. Cardiac involvement is common in AL amyloidosis and represents the single most adverse prognostic feature. A high index of clinical suspicion with rapid tissue diagnosis and commencement of combinatorial, highly effective cytoreductive therapy is crucial to arrest the process of amyloid deposition and preserve organ function. The clinical use of molecularly targeted drugs, such as proteasome inhibitors and immunomodulatory agents, monoclonal antibodies such as daratumumab, and risk-adjusted autologous stem cell transplant in eligible patients, has radically changed the natural history of AL amyloidosis. Here, we review the state-of-the-art treatment landscape in AL amyloidosis with an eye toward future therapeutic venues to impact the outcome of this devastating illness.
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Affiliation(s)
- Giada Bianchi
- Amyloidosis Program, Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yifei Zhang
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
| | - Raymond L Comenzo
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
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Hagiwara G, Arahata M, Hosokawa K, Shimojima M, Nakao S. Congestive heart failure associated with POEMS syndrome that was adequately distinguished from cardiac amyloidosis: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1266. [PMID: 34532403 PMCID: PMC8421946 DOI: 10.21037/atm-21-1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/20/2021] [Indexed: 11/22/2022]
Abstract
Congestive heart failure (CHF) is a common complication in patients with AL amyloidosis but is rare in another plasma cell dyscrasia, POEMS syndrome. A 52-year-old man developed POEMS syndrome with a solitary plasmacytoma complicated by CHF mimicking cardiac amyloidosis (CA). His neurological symptoms and CHF did not improve after radiotherapy (50 Gy) targeting the plasmacytoma. Based on typical findings of noninvasive examinations such as elevated serum NT-proBNP (12,631 pg/mL), a pseudo-infarct pattern on electrocardiography, interventricular septal thickening with a granular sparkling appearance and an apical sparing pattern of longitudinal strain on echocardiography, and late gadolinium enhancement of the left ventricular wall on cardiac magnetic resonance imaging (MRI), severe CA ineligible for autologous peripheral blood stem cell transplantation (auto-PBSCT) was strongly suspected. However, myocardial biopsy failed to reveal amyloid deposits, and CHF markedly improved after only one cycle of chemotherapy with melphalan and dexamethasone. Accordingly, CA was denied as the etiology of his heart failure, and the patient was finally diagnosed with POEMS syndrome. As a result, high-dose melphalan followed by auto-PBSCT improved his neurological symptoms. Careful evaluation is therefore needed to appropriately treat patients with POEMS syndrome complicated by CHF, even when the results of non-invasive examinations are typical for AL amyloidosis.
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Affiliation(s)
- Goshi Hagiwara
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masahisa Arahata
- Department of Internal Medicine, Nanto Municipal Hospital, Nanto, Japan
| | - Kohei Hosokawa
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masaya Shimojima
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Shinji Nakao
- Department of Hematology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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30
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Koike H, Katsuno M. Paraproteinemia and neuropathy. Neurol Sci 2021; 42:4489-4501. [PMID: 34529193 DOI: 10.1007/s10072-021-05583-7] [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: 06/16/2021] [Accepted: 08/28/2021] [Indexed: 12/16/2022]
Abstract
Paraproteinemia is associated with different peripheral neuropathies. The major causes of neuropathy correlated with paraproteinemia are the deposition of immunoglobulin in the myelin, represented by anti-myelin-associated glycoprotein (MAG) neuropathy; deposition of immunoglobulin or its fragment in the interstitium, represented by immunoglobulin light chain amyloidosis (AL amyloidosis); and paraneoplastic mechanisms that cannot be solely attributed to the deposition of immunoglobulin or its fragment, represented by polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin change (POEMS) syndrome. Patients with anti-MAG neuropathy and POEMS syndrome present with slowing of nerve conduction parameters. This characteristic fulfills the electrodiagnostic criteria for chronic inflammatory demyelinating polyneuropathy (CIDP) defined by the European Academy of Neurology and Peripheral Nerve Society (EAN/PNS). Although direct damage caused by the deposition of amyloid can induce axonal damage in AL amyloidosis, some patients with this condition have features fulfilling the EAN/PNS electrodiagnostic criteria for CIDP. Conventional immunotherapies for CIDP, such as steroids, intravenous immunoglobulin, and plasma exchange, offer no or only minimal-to-modest benefit. Although rituximab can reduce the level of circulating autoantibodies, it may only be effective in some patients with anti-MAG neuropathy. Drugs including melphalan, thalidomide, lenalidomide, and bortezomib for POEMS syndrome and those including melphalan, thalidomide, lenalidomide, pomalidomide, bortezomib, ixazomib, and daratumumab for AL amyloidosis are considered. Since there will be more therapeutic options in the future, thereby enabling appropriate treatments for individual neuropathies, there is an increasing need for early diagnosis.
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Affiliation(s)
- Haruki Koike
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan.
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, 466-8550, Japan
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31
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Simões MV, Fernandes F, Marcondes-Braga FG, Scheinberg P, Correia EDB, Rohde LEP, Bacal F, Alves SMM, Mangini S, Biolo A, Beck-da-Silva L, Szor RS, Marques W, Oliveira ASB, Cruz MW, Bueno BVK, Hajjar LA, Issa AFC, Ramires FJA, Coelho OR, Schmidt A, Pinto IMF, Rochitte CE, Vieira MLC, Mesquita CT, Ramos CD, Soares-Junior J, Romano MMD, Mathias W, Garcia MI, Montera MW, de Melo MDT, Silva SME, Garibaldi PMM, de Alencar AC, Lopes RD, de Ávila DX, Viana D, Saraiva JFK, Canesin MF, de Oliveira GMM, Mesquita ET. Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis - 2021. Arq Bras Cardiol 2021; 117:561-598. [PMID: 34550244 PMCID: PMC8462947 DOI: 10.36660/abc.20210718] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Marcus V. Simões
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Fabio Fernandes
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Philip Scheinberg
- Hospital da Beneficência Portuguesa de São PauloSão PauloSPBrasilHospital da Beneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Edileide de Barros Correia
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Luis Eduardo P. Rohde
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Fernando Bacal
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil
| | - Sandrigo Mangini
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Andréia Biolo
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
| | - Luis Beck-da-Silva
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Roberta Shcolnik Szor
- Fundação Faculdade de MedicinaSão PauloSPBrasilFundação Faculdade de Medicina, São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Wilson Marques
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, São Paulo, SP – Brasil
| | - Márcia Waddington Cruz
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Bruno Vaz Kerges Bueno
- Faculdade de Ciências Médicas da Santa Casa de São PauloSão PauloSPBrasilFaculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP – Brasil
| | - Ludhmila Abrahão Hajjar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Aurora Felice Castro Issa
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Felix José Alvarez Ramires
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Otavio Rizzi Coelho
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - André Schmidt
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | | | - Carlos Eduardo Rochitte
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital do CoraçãoSão PauloSPBrasilHospital do Coração (HCor), São Paulo, SP – Brasil
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
| | - Marcelo Luiz Campos Vieira
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Cláudio Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
| | - Celso Dario Ramos
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - José Soares-Junior
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Minna Moreira Dias Romano
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Wilson Mathias
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Marcelo Iório Garcia
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | | | | | | | - Pedro Manoel Marques Garibaldi
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Aristóteles Comte de Alencar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | | | - Diane Xavier de Ávila
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
- Complexo Hospitalar de NiteróiRio de JaneiroRJBrasilComplexo Hospitalar de Niterói, Rio de Janeiro, RJ – Brasil
- Hospital e Maternidade Christóvão da GamaSanto AndréSPBrasilHospital e Maternidade Christóvão da Gama, Santo André, SP – Brasil
- Hospital Universitário Antônio PedroRio de JaneiroRJBrasilHospital Universitário Antônio Pedro (Huap), Rio de Janeiro, RJ – Brasil
| | - Denizar Viana
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ – Brasil
| | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e InstruçãoCampinasSPBrasilSociedade Campineira de Educação e Instrução, Campinas, SP – Brasil
| | - Manoel Fernandes Canesin
- Universidade Estadual de LondrinaLondrinaPRBrasilHospital Universitário da Universidade Estadual de Londrina, Londrina, PR – Brasil
| | - Glaucia Maria Moraes de Oliveira
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Evandro Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
- Centro de Ensino e Treinamento Edson de Godoy BuenoRio de JaneiroRJBrasilCentro de Ensino e Treinamento Edson de Godoy Bueno/UHG, Rio de Janeiro, RJ – Brasil
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Deshpande PP, Jhaveri KD. The role of the kidney in AL amyloidosis. Nephrol Dial Transplant 2021; 36:1597-1599. [PMID: 31750925 DOI: 10.1093/ndt/gfz240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Priya P Deshpande
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
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Abstract
Amyloidosis constitutes a large spectrum of diseases characterized by an extracellular deposition of a fibrillar aggregate, generating insoluble and toxic amasses that may be deposited in tissues in bundles with an abnormal cross-β-sheet conformation, known as amyloid. Amyloid may lead to a cell damage and an impairment of organ function. Several different proteins are recognized as able to produce amyloid fibrils with a different tissue tropism related to the molecular structure. The deposition of amyloid may occur as a consequence of the presence of an abnormal protein, caused by high plasma levels of a normal protein, or as a result of the aging process along with some environmental factors. Although amyloidosis is rare, amyloid deposits play a role in several conditions as degenerative diseases. Thus, the development of antiamyloid curative treatments may be a rational approach to treat neurodegenerative conditions like Alzheimer's disease in the future. Nowadays, novel treatment options are currently refined through controlled trials, as new drug targets and different therapeutic approaches have been identified and validated through modern advances in basic research. Fibril formation stabilizers, proteasome inhibitors, and immunotherapy revealed promising results in improving the outcomes of patients with systemic amyloidosis, and these novel algorithms will be effectively combined with current treatments based on chemotherapeutic regimens. The aim of this review is to provide an update on diagnosis and treatment for systemic amyloidosis.
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Elsayed M, Usher S, Habib MH, Ahmed N, Ali J, Begemann M, Shabbir SA, Shune L, Al-Hilli J, Cossor F, Sperry BW, Raza S. Current Updates on the Management of AL Amyloidosis. J Hematol 2021; 10:147-161. [PMID: 34527111 PMCID: PMC8425803 DOI: 10.14740/jh866] [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: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022] Open
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is a rare but fatal disease. It results from clonal proliferation of plasma cells with excessive production of insoluble misfolded proteins that aggregate in the extracellular matrix, causing damage to the normal architecture and function of various organs. For decades, treatment for AL amyloidosis was based mainly on therapeutic agents previously studied for its more common counterpart, multiple myeloma. As the prevalence and incidence of AL amyloidosis have increased, ongoing research has been conducted with treatments typically used in myeloma with varying success. In this review, we focus on current treatment strategies and updates to clinical guidelines and therapeutics for AL amyloidosis.
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Affiliation(s)
- Marwa Elsayed
- St Luke’s Hospital of Kansas City, University of Missouri Kansas City, Wornall Rd, Kansas City, MO 64111, USA
| | - Sara Usher
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | - Muhammad Hamza Habib
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA
| | - Nausheen Ahmed
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jawad Ali
- West Midland Deanery, 213 Hagley Road, Birmingham, B16 9RG, UK
| | - Madeline Begemann
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | | | - Leila Shune
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jaffar Al-Hilli
- University of Missouri Columbia, 1 Hospital Dr, Columbia, MO 65212, USA
| | - Furha Cossor
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | - Brett W. Sperry
- Mid America Heart Institute, St Luke’s Hospital of Kansas City, Wornall Rd, Kansas City, MO 64111, USA
| | - Shahzad Raza
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
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35
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Adam RD, Coriu D, Jercan A, Bădeliţă S, Popescu BA, Damy T, Jurcuţ R. Progress and challenges in the treatment of cardiac amyloidosis: a review of the literature. ESC Heart Fail 2021; 8:2380-2396. [PMID: 34089308 PMCID: PMC8318516 DOI: 10.1002/ehf2.13443] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac amyloidosis is a restrictive cardiomyopathy determined by the accumulation of amyloid, which is represented by misfolded protein fragments in the cardiac extracellular space. The main classification of systemic amyloidosis is determined by the amyloid precursor proteins causing a very heterogeneous disease spectrum, but the main types of amyloidosis involving the heart are light chain (AL) and transthyretin amyloidosis (ATTR). AL, in which the amyloid precursor is represented by misfolded immunoglobulin light chains, can involve almost any system carrying the worst prognosis among amyloidosis patients. This has however dramatically improved in the last few years with the increased usage of the novel therapies such as proteasome inhibitors and haematopoietic cell transplantation, in the case of timely diagnosis and initiation of treatment. The treatment for AL is directed by the haematologist working closely with the cardiologist when there is a significant cardiac involvement. Transthyretin (TTR) is a protein that is produced by the liver and is involved in the transportation of thyroid hormones, especially thyroxine and retinol binding protein. ATTR results from the accumulation of transthyretin amyloid in the extracellular space of different organs and systems, especially the heart and the nervous system. Specific therapies for ATTR act at various levels of TTR, from synthesis to deposition: TTR tetramer stabilization, oligomer aggregation inhibition, genetic therapy, amyloid fibre degradation, antiserum amyloid P antibodies, and antiserum TTR antibodies. Treatment of systemic amyloidosis has dramatically evolved over the last few years in both AL and ATTR, improving disease prognosis. Moreover, recent studies revealed that timely treatment can lead to an improvement in clinical status and in a regression of amyloid myocardial infiltration showed by imaging, especially by cardiac magnetic resonance, in both AL and ATTR. However, treating cardiac amyloidosis is a complex task due to the frequent association between systemic congestion and low blood pressure, thrombo-embolic and haemorrhagic risk balance, patient frailty, and generally poor prognosis. The aim of this review is to describe the current state of knowledge regarding cardiac amyloidosis therapy in this constantly evolving field, classified as treatment of the cardiac complications of amyloidosis (heart failure, rhythm and conduction disturbances, and thrombo-embolic risk) and the disease-modifying therapy.
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Affiliation(s)
- Robert Daniel Adam
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Daniel Coriu
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Andreea Jercan
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Sorina Bădeliţă
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Bogdan A. Popescu
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Thibaud Damy
- French Referral Center for Cardiac AmyloidosisAmyloidosis Mondor NetworkCréteilFrance
- Department of CardiologyHenri Mondor Hospital/AP‐HPCréteilFrance
| | - Ruxandra Jurcuţ
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
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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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Al Hamed R, Bazarbachi AH, Bazarbachi A, Malard F, Harousseau JL, Mohty M. Comprehensive Review of AL amyloidosis: some practical recommendations. Blood Cancer J 2021; 11:97. [PMID: 34006856 PMCID: PMC8130794 DOI: 10.1038/s41408-021-00486-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/11/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is among the more common and more severe of the amyloidoses usually involving the slow proliferation of a bone-marrow-residing plasma cell (PC) clone and the secretion of unstable immunoglobulin-free light chains (FLC) that infiltrate peripheral tissues and result in detrimental end-organ damage. Disease presentation is rather vague, and the hallmark of treatment is early diagnosis before irreversible end-organ damage. Once diagnosed, treatment decision is transplant-driven whereby ~20% of patients are eligible for autologous stem cell transplantation (ASCT) with or without bortezomib-based induction. In the setting of ASCT-ineligibility, bortezomib plays a central role in upfront treatment with the recent addition of daratumumab to the current emerging standard of care. In general, management of AL amyloidosis is aimed at achieving deep, durable responses with very close monitoring for early detection of relapse/refractory disease. This article provides a comprehensive review of the management of patients with AL amyloidosis including goals of therapy, current treatment guidelines in the setting of both ASCT-eligibility and ineligibility, treatment response monitoring recommendations, toxicity management, and treatment of relapse/refractory disease.
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Affiliation(s)
- Rama Al Hamed
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Abdul Hamid Bazarbachi
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, Paris, France
| | - Jean-Luc Harousseau
- Institut de Cancerologie de l'Ouest, Centre René Gauducheau, Nantes-St Herblain, France
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, Paris, France.
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Abstract
Amyloidosis is a disorder characterized by misfolded precursor proteins that form depositions of fibrillar aggregates with an abnormal cross-beta-sheet conformation, known as amyloid, in the extracellular space of several tissues. Although there are more than 30 known amyloidogenic proteins, both hereditary and non-hereditary, cardiac amyloidosis (CA) typically arises from either misfolded transthyretin (ATTR amyloidosis) or immunoglobulin light-chain aggregation (AL amyloidosis). Its prevalence is more common than previously thought, especially among patients with heart failure and preserved ejection fraction (HFpEF) and aortic stenosis. If there is a clinical suspicion of CA, focused echocardiography, laboratory screening for the presence of a monoclonal protein (serum and urinary electrophoresis with immunofixation and serum free light-chain ratio), and cardiac scintigraphy with 99mtechnetium-labeled bone-tracers are sensitive and specific initial diagnostic tests. In some cases, more advanced/invasive techniques are necessary and, in the last several years, treatment options for both AL CA and ATTR CA have rapidly expanded. It is important to note that the aims of therapy are different. Systemic AL amyloidosis requires treatment targeted against the abnormal plasma cell clone, whereas therapy for ATTR CA must be targeted to the production and stabilization of the TTR molecule. It is likely that a multistep treatment approach will be optimal for both AL CA and ATTR CA. Additionally, treatment of CA includes the management of restrictive cardiomyopathy with preserved or reduced ejection fraction in addition to treating the amyloid deposition. Future studies are necessary to define optimal management strategies for AL CA and ATTR CA and confirm cardiac response to therapy.
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Affiliation(s)
- Petra Nijst
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - WH Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Nuvolone M, Basset M, Palladini G. A safety review of drug treatments for patients with systemic immunoglobulin light chain (AL) amyloidosis. Expert Opin Drug Saf 2021; 20:411-426. [PMID: 33583294 DOI: 10.1080/14740338.2021.1890023] [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: 10/22/2022]
Abstract
INTRODUCTION In AL amyloidosis, a usually small plasma cell clone secretes unstable, amyloid-forming light chains, causing cytotoxicity and progressive (multi)organ function deterioration. Treatment aims at reducing/eradicating the underlying clone, to reduce/zero the supply of the amyloidogenic protein and halt the amyloidogenic cascade. AREAS COVERED Safety data of alkylating agents, proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies from clinical trials are reviewed. EXPERT OPINION Drugs used to treat AL amyloidosis are derived from experience with multiple myeloma or other B cell malignancies. However, treating AL amyloidosis is particularly challenging, as it implies delivering anti-neoplastic therapy to a hematologic malignancy directly causing (multi)organ function deterioration, often in elderly subjects with other comorbidities and polypharmacotherapy. This unique combination translates in increased patients' frailty and higher sensitivity toward treatment-related toxicities. Therefore, dose/schedule adjustments and special precautions are needed when translating treatment experience from multiple myeloma or other B cell malignancies to AL amyloidosis. Treatment of patients with AL amyloidosis should be risk adapted, tailored to individual patients' risk profile, considering the type and extent of organ involvement, and eventual comorbidity. As several classes of effective anti-plasma cell or B cell drugs are available, therapeutic choices are also influenced by individual drug's safety profile.
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Affiliation(s)
- Mario Nuvolone
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marco Basset
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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40
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Sharpley FA, Manwani R, Petrie A, Mahmood S, Sachchithanantham S, Lachmann HJ, Martinez De Azcona Naharro A, Gillmore JD, Whelan CJ, Fontana M, Cohen O, Hawkins PN, Wechalekar AD. Autologous stem cell transplantation vs bortezomib based chemotheraphy for the first-line treatment of systemic light chain amyloidosis in the UK. Eur J Haematol 2021; 106:537-545. [PMID: 33460466 DOI: 10.1111/ejh.13582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/13/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The benefit of autologous stem cell transplantation (ASCT) in the treatment of light chain (AL) amyloidosis requires re-evaluation in the modern era. This retrospective case-matched study compares ASCT to bortezomib for the treatment of patients with AL amyloidosis. METHODS Newly diagnosed patients with AL amyloidosis treated with ASCT or bortezomib between 2001 and 2018 were identified. Patients were excluded if the time from diagnosis to treatment exceeded 12 months. Patients were matched on a 1:1 basis, using a propensity-matched scoring approach. RESULTS A total of 136 propensity score-matched patients were included (ASCT n = 68, bortezomib n = 68). There was no significant difference in overall survival at two years (P = .908, HR: 0.95, CI: 0.41-2.20). For ASCT vs bortezomib: overall haematological response rate at 6 months was 90.6% vs 92.5%; organ response at 12 months: cardiac (70.0% vs 54%, P > .999), renal (74% vs 24%, P = .463) liver (21% vs 22%, P = .048); median progression-free survival (50 vs 42 months P = .058, HR: 0.61, CI: 0.37-1.02) and time to next treatment (68 vs 45 months, P = .145, HR: 0.61, CI: 0.31-1.19). More patients required treatment in the bortezomib group compared to ASCT group at 24 months (41 vs 23, Chi-squared P = .004) and 48 months (57 vs 41, Chi-squared P = .004). CONCLUSIONS This small retrospective study suggests that there is no clear survival advantage of ASCT over bortezomib therapy. A prospective randomised controlled trial evaluating ASCT in AL amyloidosis is critically needed.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Richa Manwani
- National Amyloidosis Centre, University College London, London, UK
| | - Aviva Petrie
- Biostatistics Unit, UCL Eastman Dental Institute, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK
| | | | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | | | | | - Carol J Whelan
- National Amyloidosis Centre, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
| | - Oliver Cohen
- National Amyloidosis Centre, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
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Venetoclax induces deep hematologic remissions in t(11;14) relapsed/refractory AL amyloidosis. Blood Cancer J 2021; 11:10. [PMID: 33431806 PMCID: PMC7801694 DOI: 10.1038/s41408-020-00397-w] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 11/14/2020] [Accepted: 11/24/2020] [Indexed: 12/12/2022] Open
Abstract
Venetoclax is efficacious in relapsed/refractory t(11;14) multiple myeloma, thus warranting investigation in light-chain amyloidosis (AL). This retrospective cohort includes 43 patients with previously treated AL, from 14 centers in the US and Europe. Thirty-one patients harbored t(11;14), 11 did not, and one t(11;14) status was unknown. Patients received a venetoclax-containing regimen for at least one 21- or 28-day cycle; the median prior treatments was three. The hematologic response rate for all patients was 68%; 63% achieved VGPR/CR. t(11;14) patients had higher hematologic response (81% vs. 40%) and higher VGPR/CR rate (78% vs. 30%, odds ratio: 0.12, 95% CI 0.02–0.62) than non-t(11;14) patients. For the unsegregated cohort, median progression-free survival (PFS) was 31.0 months and median OS was not reached (NR). For t(11;14), median PFS was NR and for non-t(11;14) median PFS was 6.7 months (HR: 0.14, 95% CI 0.04–0.53). Multivariate analysis incorporating age, sex, prior lines of therapy, and disease stage suggested a risk reduction for progression or death in t(11;14) patients. Median OS was NR for either subgroup. The organ response rate was 38%; most responders harbored t(11;14). Grade 3 or higher adverse events occurred in 19% with 7% due to infections. These promising results require confirmation in a randomized clinical trial.
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Cornell RF, Fraser R, Costa L, Goodman S, Estrada-Merly N, Lee C, Hildebrandt G, Gergis U, Farhadfar N, Freytes CO, Kamble RT, Krem M, Kyle RA, Lazarus HM, Marks DI, Meehan K, Patel SS, Ramanathan M, Olsson RF, Wagner JL, Kumar S, Qazilbash MH, Shah N, Hari P, D'Souza A. Bortezomib-Based Induction Is Associated with Superior Outcomes in Light Chain Amyloidosis Patients Treated with Autologous Hematopoietic Cell Transplantation Regardless of Plasma Cell Burden. Transplant Cell Ther 2020; 27:264.e1-264.e7. [PMID: 33781533 DOI: 10.1016/j.jtct.2020.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 01/03/2023]
Abstract
The benefits of pre-transplant induction chemotherapy in light chain (AL) amyloidosis, a low burden plasma cell (PC) neoplasm associated with multiorgan dysfunction, is debatable, although with the availability of bortezomib, this approach is being increasingly pursued. We analyzed the outcomes of AL amyloidosis patients undergoing autologous hematopoietic cell transplant between 2014 and 2018 that were reported to the Center for International Blood and Marrow Transplant Research database. Of 440 patients, 294 received bortezomib-based induction, and 146 received no induction. Patients receiving induction had greater PC burden compared to no induction (PC 10% or more, 39% versus 11%; P < .01). At 2 years, the induction group compared to no induction had lower relapse/progression: 13% (9% to 18%) versus 23% (16% to 32%) (P = .02); better progression-free survival (PFS): 82% (77% to 87%) versus 69% (61% to 77%) (P < .01); and similar overall survival (OS): 92% (88% to 95%) versus 89% (84% to 94%) (P = .22), findings that were confirmed on multivariate analysis. A subset analysis limited to patients with <10% PC also showed superior relapse/progression (hazard ratio [HR], .43; 95% confidence interval [CI], .24 to .78; P < .01) and PFS (HR, .43; 95% CI, .26 to .72; P < .01) for induction compared to no induction. Thus, we conclude that pre-transplant bortezomib-based induction was associated with improved relapse/progression and PFS in AL amyloidosis. Longer survival follow-up is warranted, as OS was excellent in both cohorts at 2 years.
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Affiliation(s)
| | - Raphael Fraser
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Luciano Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stacey Goodman
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Noel Estrada-Merly
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cindy Lee
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Usama Gergis
- Department of Medical Oncology, Division of Hematological Malignancies, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainesville, FL
| | | | - Rammurti T Kamble
- Division of Hematology and Oncology, Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - Maxwell Krem
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - David I Marks
- Adult Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Kenneth Meehan
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sagar S Patel
- Blood and Marrow Transplant Program, University of Utah, Salt Lake City, Utah
| | - Muthalagu Ramanathan
- Division of Hematology and Oncology, Department of Medicine, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - John L Wagner
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Ninah Shah
- Division of Hematology-Oncology, University of California San Francisco, San Francisco, California
| | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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44
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Spoladore R, Falasconi G, Marcatti M, Di Maio S, Fiore G, Slavich M, Margonato A, Turco A, Fragasso G. Advances in pharmacotherapy for cardiac amyloidosis. Expert Opin Pharmacother 2020; 22:469-481. [PMID: 33043721 DOI: 10.1080/14656566.2020.1836159] [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] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Amyloidosis is a group of progressive and devastating disorders resulting from extracellular deposition of misfolded proteins into tissues. When deposition of fibrils occurs in cardiac tissues, this systemic disease can lead to a very poor prognosis. Systemic amyloidosis can be acquired [light chain (AL) amyloidosis; AA amyloidosis], or hereditary [transthyretin (ATTR) amyloidosis]. Cardiac disease in amyloidosis is usually secondary to a systemic disease. The diagnosis of cardiac involvement is often delayed and yields an adverse prognosis. AREAS COVERED in this review, the authors report current literature on advances in pharmacotherapy for cardiac amyloidosis, mainly focused on AL and ATTR amyloidosis treatment. EXPERT OPINION Most pharmacological trials in amyloidosis patients, both AL and TTR, are directed to study the effects of drugs on polyneuropathy. However, since cardiac involvement carries a prominent negative survival impact in amyloidosis patients, future research should be more focused on amyloidosis cardiomyopathy as primary endpoint. Additionally, in AL amyloidosis therapies are mainly derived from experience on multiple myeloma treatment. In this specific setting, possible future research could particularly focus on immunotherapeutic agents able to optimize the standard chemotherapy results and, thus, allowing a larger population of patients to be treated by bone marrow stem cell transplantation.
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Affiliation(s)
- R Spoladore
- Hypertrophic Cardiomyopathy Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Falasconi
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Marcatti
- Haematology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - S Di Maio
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Fiore
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Slavich
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - A Margonato
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - A Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - G Fragasso
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Heart Failure Unit, IRCCS San Raffaele University Hospital, Milan, Italy
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Hughes DM, Staron A, Sanchorawala V. A pharmacist's review of the treatment of systemic light chain amyloidosis. J Oncol Pharm Pract 2020; 27:187-198. [PMID: 33028132 DOI: 10.1177/1078155220963534] [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: 12/19/2022]
Abstract
OBJECTIVE Systemic light-chain (AL) amyloidosis is an uncommon hematologic plasma cell dyscrasia that is becoming increasingly recognized. Therapeutic agents used in AL amyloidosis overlap with those used in multiple myeloma; however, differences in disease features change treatment efficacy and tolerance. Pharmacists must be cognizant of these distinctions. Herein, this review article provides an up-to-date guide to treatment considerations for systemic AL amyloidosis in both the front-line and relapsed settings.Data sources: A comprehensive literature search was performed using the PubMed/Medline database for articles published through (June 2020) regarding treatments for AL amyloidosis. Search criteria included therapies that are FDA approved for multiple myeloma, as well as investigational agents. This review of chemotherapeutic agents reflects the current clinical practice guidelines endorsed by NCCN along with commentary based on the experience of pharmacists from a tertiary-referral center treating many patients with AL amyloidosis. Data consists of randomized controlled trials, observational cohorts, case reports, and ongoing clinical trials.Data summary: Frontline options discussed here include high-dose melphalan with autologous stem cell transplantation and bortezomib-based regimens. Regarding the relapsed setting, supporting data are compiled and summarized for: bortezomib, ixazomib, carfilzomib, lenalidomide, pomalidomide, daratumumab, elotuzumab, isatuximab, venetoclax, NEOD001, and melflufen. CONCLUSIONS The treatment platform for AL amyloidosis is expanding with novel agents traditionally used in multiple myeloma being adopted and modified for use in AL amyloidosis. The pharmacist's familiarity with the clinical evidence base for these agents and how they fit into standard protocols for AL amyloidosis is critical as dosing and monitoring recommendations are unique from multiple myeloma.
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Affiliation(s)
- David M Hughes
- Department of Pharmacy, Boston Medical Center, Boston, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, USA
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Pratt G. Bortezomib, Melphalan, Dexamethasone: A New Standard of Care for AL Amyloidosis? J Clin Oncol 2020; 38:3243-3244. [DOI: 10.1200/jco.20.01904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Guy Pratt
- University Hospitals Birmingham, National Health Service Foundation Trust, Birmingham, United Kingdom
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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: 7] [Impact Index Per Article: 1.8] [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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Witteles RM, Barrett CD. Reply: Should We Be for ASCT?: If Yes, Then When? JACC-HEART FAILURE 2020; 8:696-697. [PMID: 32731950 DOI: 10.1016/j.jchf.2020.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 10/23/2022]
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Kastritis E, Leleu X, Arnulf B, Zamagni E, Cibeira MT, Kwok F, Mollee P, Hájek R, Moreau P, Jaccard A, Schönland SO, Filshie R, Nicolas-Virelizier E, Augustson B, Mateos MV, Wechalekar A, Hachulla E, Milani P, Dimopoulos MA, Fermand JP, Foli A, Gavriatopoulou M, Klersy C, Palumbo A, Sonneveld P, Johnsen HE, Merlini G, Palladini G. Bortezomib, Melphalan, and Dexamethasone for Light-Chain Amyloidosis. J Clin Oncol 2020; 38:3252-3260. [PMID: 32730181 DOI: 10.1200/jco.20.01285] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Oral melphalan and dexamethasone (MDex) were considered a standard of care in light-chain (AL) amyloidosis. In the past decade, bortezomib has been increasingly used in combination with alkylating agents and dexamethasone. We prospectively compared the efficacy and safety of MDex and MDex with the addition of bortezomib (BMDex). METHODS This was a phase III, multicenter, randomized, open-label trial. Patients were stratified according to cardiac stage. Patients with advanced cardiac stage (stage IIIb) amyloidosis were not eligible. The primary end point was hematologic response rate at 3 months. This trial is registered with ClinicalTrials.gov identifier NCT01277016. RESULTS A total of 109 patients, 53 in the BMDex and 56 in the MDex group, received ≥ 1 dose of therapy (from January 2011 to February 2016). Hematologic response rate at 3 months was higher in the BMDex arm (79% v 52%; P = .002). Higher rates of very good partial or complete response rates (64% v 39%; hazard ratio [HR], 2.47; 95% CI, 1.30 to 4.71) and improved overall survival, with a 2-fold decrease in mortality rate (HR, 0.50; 95% CI, 0.27 to 0.90), were observed in the BMDex arm. Grade 3 and 4 adverse events (the most common being cytopenia, peripheral neuropathy, and heart failure) were more common in the BMDex arm, occurring in 20% versus 10% of cycles performed. CONCLUSION BMDex improved hematologic response rate and overall survival. To our knowledge, this is the first time a controlled study has demonstrated a survival advantage in AL amyloidosis. BMDex should be considered a new standard of care for AL amyloidosis.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Xavier Leleu
- Hopital Huriez Centre Hospitalier Régional Universitaire, Lille, France
| | - Bertrand Arnulf
- Immunohematology Unit, Hospital Saint-Louis, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Elena Zamagni
- Bologna University School of Medicine, Bologna, Italy
| | - María Teresa Cibeira
- Amyloidosis and Myeloma Unit, Hospital Clinic of Barcelona, August Pi i Sunyer Biomedical Research Institute, Barcelona, Spain
| | - Fiona Kwok
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Peter Mollee
- Princess Alexandra Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Roman Hájek
- Department of Hemato-oncology, University Hospital, Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | | | | | - Stefan O Schönland
- Medical Department V, Amyloidosis Centre, University Hospital, Heidelberg, Germany
| | - Robin Filshie
- St Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | - María-Victoria Mateos
- University Hospital of Salamanca, Instituto de Investigación Biosanitaria de Salamanc, Institute of Cancer Molecular and Cellular Biology, Salamanca, Spain
| | - Ashutosh Wechalekar
- University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Eric Hachulla
- Hopital Huriez Centre Hospitalier Régional Universitaire, Lille, France
| | - Paolo Milani
- Amyloidosis Research and Treatment Center "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo," Pavia, Italy
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Jean-Paul Fermand
- Immunohematology Unit, Hospital Saint-Louis, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Andrea Foli
- Amyloidosis Research and Treatment Center "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo," Pavia, Italy
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Catherine Klersy
- Clinical Epidemiology and Biometry Service, "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo," Pavia, Italy
| | | | | | | | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo," Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center "Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo," Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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A study from The Mayo Clinic evaluated long-term outcomes of kidney transplantation in patients with immunoglobulin light chain amyloidosis. Kidney Int 2020; 99:707-715. [PMID: 32712168 DOI: 10.1016/j.kint.2020.06.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/02/2020] [Accepted: 06/19/2020] [Indexed: 12/15/2022]
Abstract
Longer survival using modern therapies has increased the number of patients with immunoglobulin light-chain amyloidosis receiving kidney transplantation. We evaluated 60 patients with immunoglobulin light chain amyloidosis who underwent kidney transplantation based on their hematologic response for outcomes of death, graft failure, and complications. Patient hematologic responses (light-chain in blood or urine) prior to kidney transplantation were three patients had no response, five had a partial response, six had a very good partial response, 37 had a complete response, and nine were treatment-naive patients (never treated for this disorder). After transplantation, seven of nine treatment-naive patients achieved a complete response. The median follow-up for the entire transplant cohort was 61 months. The estimated median overall survival from the time of kidney transplantation was 123 months for the entire group. Median overall survival was not reached for the very good partial response plus complete response groups, it was 47 months for no response plus partial response groups, and 117 months for the treatment-naive group (all significantly different). Median overall survival of very good partial response was 81 months, while the median was not reached in the complete response group (no significant difference). The time to amyloid recurrence was significantly longer in complete response compared to very good partial response (median 181 vs 81 months). Death-censored graft survival at one- and five-years was 98.3%, and 95.8%, respectively for all groups. Of the 60 patients, three had allograft failure, 19 died with a functioning graft, and 13 had an amyloid recurrence. Thus, outcomes after kidney transplant in patients with immunoglobulin light-chain amyloidosis seem acceptable if a very good partial response or complete response is achieved either before or after transplantation.
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