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Mustafa A, Wei C, Araji G, Niazi MRK, Grovu R, Weinberg M, Lafferty J. Monoclonal Gammopathy of Undetermined Significance and Associated Cardiovascular Outcomes in a Hospital Setting-A Fresh Perspective. Curr Oncol 2024; 31:4432-4442. [PMID: 39195314 DOI: 10.3390/curroncol31080331] [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: 06/18/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/29/2024] Open
Abstract
There is a paucity of data on the cardiovascular implications of monoclonal gammopathy of undetermined significance, especially among hospitalized patients. Our study aimed to investigate the association between MGUS and cardiovascular outcomes in a hospital setting using the National Inpatient Sample database. MGUS patients were sampled using ICD-10 codes. The patients were stratified into two cohorts based on the presence or absence of MGUS. Comorbidities and cardiovascular outcomes were collected using ICD 10 DM codes. CV outcomes were evaluated before and after 1:1 matching for age, gender, and race. Furthermore, a sensitivity analysis was performed on the matched population, which excluded patients with diabetes mellitus, prior myocardial infarction, chronic kidney disease (stages 3-5), dialysis, hypertension, obesity, metabolic syndrome, cancer, antiplatelets, and oral anticoagulant use and was adjusted for smoking, dyslipidemia, and aspirin use to evaluate the cardiovascular outcomes. MGUS patients had more heart failure, atrial fibrillation, venous thromboembolism, aortic aneurysm, aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, conduction disorder, cor pulmonale, peripheral vascular disease, and acute myocardial infarction. After matching, MGUS was associated with heart failure, atrial fibrillation, venous thromboembolism, aortic stenosis, mitral regurgitation, conduction disorder, cor pulmonale, and peripheral vascular disease. MGUS was linked to a wide spectrum of cardiovascular diseases in an inpatient setting. Further studies are needed to formulate appropriate recommendations for the screening and management of cardiovascular complications in individuals with MGUS.
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Affiliation(s)
- Ahmad Mustafa
- Department of Cardiology, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - Chapman Wei
- Department of Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - Ghada Araji
- Department of Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - Muhammad Rafay Khan Niazi
- Department of Hematology and Oncology, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - Radu Grovu
- Department of Internal Medicine, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - Mitchell Weinberg
- Department of Cardiology, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
| | - James Lafferty
- Department of Cardiology, Northwell Health/Staten Island University Hospital, Staten Island, New York, NY 10305, USA
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Kurisu S, Fujiwara H. Deep vein thrombosis in a patient with wild-type transthyretin cardiac amyloidosis. J Cardiol Cases 2024; 29:218-221. [PMID: 39100518 PMCID: PMC11295011 DOI: 10.1016/j.jccase.2024.01.005] [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: 11/08/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 08/06/2024] Open
Abstract
Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is a progressive myocardial disease characterized by an increased ventricular wall thickness. ATTRwt-CA is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein) on serum immunofixation electrophoresis. Increasing evidence has emerged regarding the risk of venous thromboembolic disease in patients with MGUS. Herein, we report a case of ATTRwt-CA with M-protein, where the patient developed deep vein thrombosis (DVT). A 72-year-old man presented with gradual progressive swelling of the right lower extremity. He had undergone surgical treatment for bilateral carpal syndrome and lumbar spinal canal stenosis. He was diagnosed with DVT and severe left ventricular (LV) hypertrophy, and was treated with a direct factor Xa inhibitor. Given severe LV hypertrophy, the patient underwent further cardiac examinations. 99mTc-labelled pyrophosphate scintigraphy revealed grade 3 myocardial uptake. Serum immunofixation electrophoresis detected IgA-κ M-protein. An endomyocardial biopsy revealed amyloid deposits. Based on immunohistochemical staining and genetic testing, the patient was diagnosed as having ATTRwt-CA with IgA-κ M-protein. Therefore, clinicians should be aware that ATTRwt-CA is often associated with M-protein. Under these conditions, attention should be paid to both pathological issues. Learning objective Wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is often accompanied by monoclonal gammopathy of undetermined significance (MGUS), as indicated by an abnormal serum-free light chain ratio or detection of monoclonal protein (M-protein). Meanwhile, increasing evidence has emerged about the risk of deep vein thrombosis (DVT) in patients with MGUS. We report a case of ATTRwt-CA with M-protein, in which DVT developed. Under these conditions, paying attention to both pathological aspects is warranted.
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Affiliation(s)
- Satoshi Kurisu
- Department of Cardiology, NHO Hiroshimanishi Medical Center, Otake, Japan
| | - Hitoshi Fujiwara
- Department of Cardiology, NHO Hiroshimanishi Medical Center, Otake, Japan
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Ghansah H, Orbán-Kálmándi R, Debreceni IB, Katona É, Rejtő L, Váróczy L, Lóczi L, de Laat B, Huskens D, Kappelmayer J, Bagoly Z. Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma. Thromb Res 2024; 234:12-20. [PMID: 38134612 DOI: 10.1016/j.thromres.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/13/2023] [Accepted: 12/11/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood. OBJECTIVES To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients. METHODS FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test. RESULTS FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis. CONCLUSIONS Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rita Orbán-Kálmándi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - Linda Lóczi
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Bas de Laat
- Synapse Research Institute, Maastricht, the Netherlands
| | - Dana Huskens
- Synapse Research Institute, Maastricht, the Netherlands
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Department of Laboratory Medicine, Faculty of Medicine, Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary; Hungarian Research Network (HUN-REN-DE) Cerebrovascular Research Group, Debrecen, Hungary.
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Wang Y, Yang K, Yu Z, Huang Y, He T, Xiong J, Zhao J. The clinical value of monoclonal protein in ANCA-associated vasculitis with renal involvement. Int Urol Nephrol 2023; 55:2925-2933. [PMID: 37010735 DOI: 10.1007/s11255-023-03579-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/25/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE The value of monoclonal protein (M-protein) in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) patients with renal involvement has not been investigated. METHODS We analyzed AAV patients with renal involvement from 2013 to 2019 in our center. Patients with immunofixation electrophoresis were divided into M-protein positive group and M-protein negative group. The clinicopathological features and outcomes of the two groups were compared. RESULTS Ninety-one AAV patients with renal involvement were enrolled for analysis, and 16 patients (17.6%) had a positive test for M-protein. Compared with M-protein negative patients, M-protein positive patients had lower hemoglobin (77.6 vs 88.4 g/L, p = 0.016), mean corpuscular hemoglobin concentration (313 vs 323 g/L, p = 0.002),serum albumin (29.4 vs 32.5 g/L, p = 0.026) and complement 3 (C3) (0.66 vs 0.81 g/L, p = 0.047), while higher platelets (252 vs 201 109/L, p = 0.048) and incidence of pulmonary infection (62.5% vs 33.3%, p = 0.029). However, renal pathological features between the two groups had no significant difference. In addition, during a median follow-up of 33 months, Kaplan-Meier survival analysis showed that, compared with M-protein negative patients, M-protein positive patients had a higher risk of all-cause mortality (log-rank test, p = 0.028), especially for patients who were not dialysis-dependent at the time of admission (log-rank test, p = 0.012). CONCLUSION Our results indicate that M-protein is associated with different clinicopathological features and increased all-cause mortality in AAV patients with renal involvement. Testing M-protein and rigorous diagnosing of the significance of the presence of M-protein may be helpful for assessing the survival of AAV patients with renal involvement.
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Affiliation(s)
- Yue Wang
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China
| | - Ke Yang
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China
| | - Zhikai Yu
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China
| | - Yinghui Huang
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China
| | - Ting He
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China
| | - Jiachuan Xiong
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China.
| | - Jinghong Zhao
- Department of Nephrology, Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Chongqing Clinical Research Center of Kidney and Urology Diseases, Xinqiao Hospital, Army Medical University, (Third Military Medical University), Chongqing, 400037, China.
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Kanack AJ, Schaefer JK, Sridharan M, Splinter NP, Kohlhagen MC, Singh B, De Lorenzo SB, Mauch EE, Hussein MA, Shaikh M, Kumar S, Wen R, Wang D, Murray D, Padmanabhan A. Monoclonal gammopathy of thrombotic/thrombocytopenic significance. Blood 2023; 141:1772-1776. [PMID: 36626584 PMCID: PMC10113173 DOI: 10.1182/blood.2022018797] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/27/2022] [Accepted: 12/27/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Adam J. Kanack
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Noah P. Splinter
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mindy C. Kohlhagen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Bandana Singh
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Emily E. Mauch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Marwan Shaikh
- Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Shaji Kumar
- Department of Medicine, Mayo Clinic, Rochester, MN
| | - Renren Wen
- Department of Microbiology and Immunology, Versiti Blood Research Institute and Medical College of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Department of Microbiology and Immunology, Versiti Blood Research Institute and Medical College of Wisconsin, Milwaukee, WI
| | - David Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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Acute venous thromboembolic events in patients with monoclonal gammopathy of undetermined significance: An analysis of the National Inpatient Sample. Thromb Res 2023; 225:28-32. [PMID: 36933476 DOI: 10.1016/j.thromres.2023.02.014] [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: 11/08/2022] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Monoclonal Gammopathy of Undetermined Significance (MGUS) is a premalignant plasma cell disorder which despite being clinically silent carries an increased risk of venous thromboembolism (VTE). We conducted a population-based study to investigate the risk of VTE in these patients. METHODS We utilized the National Inpatient Sample (NIS) for the year 2016 to compare the incidence of acute VTE between patients who carry the diagnosis of MGUS and those who don't. We excluded hospitalizations with age < 18 years and those that had a diagnosed lymphoma, leukemia, solid malignancy, or other plasma cell dyscrasia. We utilized the ICD-10-CM coding system to search the database for codes of VTE, MGUS, and other comorbid conditions. Multivariate logistic regression models were used for comparative analysis adjusting for demographic characteristics and comorbidities. Baseline comorbidities were described as frequencies and proportions for categorical variables and as medians with interquartile ranges for continuous variables. RESULTS A total of 33,115 weighted hospitalizations were included in the MGUS group. These were compared to 27,418,403 weighted hospitalizations without the diagnosis of MGUS. The MGUS group had higher odds of composite venous thromboembolism (adjusted OR 1.33, 95 % CI 1.22-1.44), deep vein thrombosis (adjusted OR 1.46, 95 % CI 1.29-1.65), and pulmonary embolism (adjusted OR 1.22, 95 % CI 1.09-1.37). CONCLUSION Patients with MGUS had increased odds of developing acute venous thromboembolism compared to patients with no history of MGUS.
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Ghansah H, Debreceni IB, Váróczy L, Rejtő L, Lóczi L, Bagoly Z, Kappelmayer J. Patients with multiple myeloma and monoclonal gammopathy of undetermined significance have variably increased thrombin generation and different sensitivity to the anticoagulant effect of activated protein C. Thromb Res 2023; 223:44-52. [PMID: 36708689 DOI: 10.1016/j.thromres.2023.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/02/2023] [Accepted: 01/11/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Patients with multiple myeloma (MM) are at high risk of thrombosis especially when receiving immunomodulatory therapy. Thrombotic risk in patients with monoclonal gammopathy of undetermined significance (MGUS) may also be increased. Although activated protein C (APC) resistance has been linked to an increased risk of thrombosis in MM, little is known about how APC influences thrombotic risk in MGUS. We compared thrombin generation (TG) in MM and MGUS patients to that of healthy controls (HCs) and investigated the exogenous effect of APC on TG in these groups. METHODS Hemostasis tests including factor VIII (FVIII) and von Willebrand factor (vWF) levels were measured in platelet-poor plasma in 14 untreated MM patients, 34 MGUS patients, and 30 age and sex-matched HCs. TG assay was performed with or without the addition of APC. RESULTS Peak thrombin and velocity index were significantly higher in MM and MGUS patients compared to HCs, while MM patients also had elevated endogenous thrombin potential (ETP). In MGUS cases, ETP and peak thrombin values significantly correlated with FVIII and vWF levels. In the presence of APC, peak thrombin and ETP were reduced in MGUS and control plasmas whereas lagtime and time to peak were significantly prolonged. In contrast, adding APC to MM plasma had no effect on any TG parameters. CONCLUSIONS Hypercoagulability was observed in MM and even in MGUS cases with very low monoclonal protein concentration. In MM patients, APC had no effect on TG, but it attenuated TG in MGUS patients.
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Affiliation(s)
- Harriet Ghansah
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Kálmán Laki Doctoral School, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ildikó Beke Debreceni
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Váróczy
- Department of Internal Medicine, Division of Hematology, University of Debrecen, Debrecen, Hungary
| | - László Rejtő
- Department of Hematology, Jósa András Teaching Hospital, Nyíregyháza, Hungary
| | - Linda Lóczi
- Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - Zsuzsa Bagoly
- Division of Clinical Laboratory Sciences, University of Debrecen, Debrecen, Hungary
| | - János Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
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Gkalea V, Fotiou D, Dimopoulos MA, Kastritis E. Monoclonal Gammopathy of Thrombotic Significance. Cancers (Basel) 2023; 15:cancers15020480. [PMID: 36672429 PMCID: PMC9856365 DOI: 10.3390/cancers15020480] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
The current review provides an overview of the thrombotic risk observed in patients with MG who do not otherwise require treatment. We discuss clinical and biomarker studies that highlight the heterogenous hemostatic profile observed in these patients and how knowledge has evolved over the past 20 years. Biomarker studies suggest shared biologic features between multiple myeloma and monoclonal gammopathy of undetermined significance (MGUS), which involves both hypercoagulability and platelet activation. Hemostatic abnormalities identified in MGUS patients cannot be translated into clinical practice as they lack correlation to clinical events. The prothrombotic phenotype of MGUS patients has not been ascertained yet, but novel data on coagulation markers are promising. We also review rare conditions associated with the thrombogenic properties of the monoclonal protein that predispose to arterial, venous or microthrombotic events and demonstrate that the M-protein can be linked to clinically significant thrombotic events. Cryoglobulinemia, cryofibrinogenemia, cryo-crystaloglobulinemia and MG-related antiphospholipid syndrome are reviewed. We propose the new umbrella term "monoclonal gammopathy of thrombotic significance" (MGTS) to refer to significant, recurrent thrombotic events in patients with MGUS that provide a rationale for targeting the underlying plasma cell clone. Identifying MGUS patients at high risk for thrombotic events is currently a challenge.
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Fotiou D, Dimopoulos MA, Kastritis E. Approach to Contemporary Risk Assessment, Prevention and Management of Thrombotic Complications in Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14246216. [PMID: 36551701 PMCID: PMC9777181 DOI: 10.3390/cancers14246216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is associated with an increased risk of thrombotic complications, which remains substantial despite the implementation of thromboprophylaxis. The procoagulant state that characterizes the disease is multifactorial, and a greater understanding of the underlying pathophysiology is required to inform appropriate thrombosis prevention. Currently, there is a shift towards using direct oral anticoagulants (DOACs) in this setting; head-to-head comparisons in the context of controlled clinical trials between class agents are still missing. MM-specific VTE risk assessment scores have been developed to optimize management and minimize the associated mortality/morbidity. Their clinical utility remains to be evaluated. The value of adding biomarkers to clinical scores to optimize their performance and increase their discriminatory power is also under assessment.
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[Expert consensus on the prevention and treatment of multiple myeloma related venous thromboembolism in China (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:726-731. [PMID: 36709165 PMCID: PMC9613487 DOI: 10.3760/cma.j.issn.0253-2727.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 12/05/2022]
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Nielsen T, Kristensen SR, Gregersen H, Teodorescu EM, Pedersen S. Prothrombotic abnormalities in patients with multiple myeloma and monoclonal gammopathy of undetermined significance. Thromb Res 2021; 202:108-118. [PMID: 33819778 DOI: 10.1016/j.thromres.2021.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multiple myeloma (MM) and its precursor condition, monoclonal gammopathy of undetermined significance (MGUS) have an increased risk of thrombotic events, especially during anti-myeloma treatment. Many different underlying causes for this hypercoagulability have been suggested, but current techniques to identify abnormalities in these patients are sparse and inefficient. The aim of this study was to assess the hypercoagulability in MGUS and MM patients through various coagulation analyses and identify changes in the MM patients throughout their treatment regimen. MATERIALS AND METHODS Platelet-free plasma from 38 MM patients, 19 MGUS patients and 34 healthy controls were tested for hypercoagulability using calibrated automated thrombogram, a procoagulant phospholipid assay, a microvesicle-associated (MV) tissue factor (TF) assay, and a cell-free deoxyribonucleic acid (cf-DNA) assay as a surrogate measurement for neutrophil extracellular traps (NETs). RESULTS MGUS and MM patients both had elevated thrombin generation and procoagulant phospholipid activity in comparison to the control subjects. MM, and partly MGUS, showed increased MV-TF activity, however, only MM had increased levels of the cf-DNA. CONCLUSIONS Here we demonstrated that hypercoagulability was present in patients with MGUS and MM through increased thrombin generation, possibly due to higher TF and procoagulant phospholipids (PPL) activity. This may be associated to MVs and, for MM patients, be attributed to procoagulant NETs activity; however, this remains to be determined.
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Affiliation(s)
- Thøger Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Søren Risom Kristensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | | | | | - Shona Pedersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Romano A, Cerchione C, Conticello C, Martinelli G, Di Raimondo F. How we manage smoldering multiple myeloma. Hematol Rep 2020; 12:8951. [PMID: 33042502 PMCID: PMC7520850 DOI: 10.4081/hr.2020.8951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Indexed: 11/23/2022] Open
Abstract
Smoldering myeloma (SMM) is an asymptomatic stage characterized by bone marrow plasma cells infiltration between 10-60% in absence of myeloma-defining events and organ damage. Until the revision of criteria of MM to require treatment, two main prognostic models, not overlapping each other, were proposed and used differently in Europe and in US. Novel manageable drugs, like lenalidomide and monoclonal antibodies, with high efficacy and limited toxicity, improvement in imaging and prognostication, challenge physicians to offer early treatment to highrisk SMM. Taking advantage from the debates offered by SOHO Italy, in this review we will update the evidence and consequent clinical practices in US and Europe to offer readers a uniform view of clinical approach at diagnosis, follow-up and supportive care in the SMM setting.
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Affiliation(s)
- Alessandra Romano
- Dipartimento di Chirurgia e Specialità Medico-Chirurgiche, Sezione di Ematologia, Università degli Studi di Catania
| | - Claudio Cerchione
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC)
| | - Concetta Conticello
- U.O.C. di Ematologia, Azienda Policlinico Rodolico San Marco, Catania, Italy
| | - Giovanni Martinelli
- Hematology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola (FC)
| | - Francesco Di Raimondo
- Dipartimento di Chirurgia e Specialità Medico-Chirurgiche, Sezione di Ematologia, Università degli Studi di Catania
- U.O.C. di Ematologia, Azienda Policlinico Rodolico San Marco, Catania, Italy
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Lomas OC, Mouhieddine TH, Tahri S, Ghobrial IM. Monoclonal Gammopathy of Undetermined Significance (MGUS)-Not So Asymptomatic after All. Cancers (Basel) 2020; 12:E1554. [PMID: 32545521 PMCID: PMC7352603 DOI: 10.3390/cancers12061554] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/07/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is considered to be a benign precursor condition that may progress to a lymphoproliferative disease or multiple myeloma. Most patients do not progress to an overt condition, but nevertheless, MGUS is associated with a shortened life expectancy and, in a minority of cases, a number of co-morbid conditions that include an increased fracture risk, renal impairment, peripheral neuropathy, secondary immunodeficiency, and cardiovascular disease. This review aims to consolidate current evidence for the significance of these co-morbidities before considering how best to approach these symptoms and signs, which are often encountered in primary care or within a number of specialties in secondary care.
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Affiliation(s)
- Oliver C. Lomas
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
| | - Tarek H. Mouhieddine
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sabrin Tahri
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
| | - Irene M. Ghobrial
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA; (O.C.L.); (T.H.M.); (S.T.)
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14
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O'Sullivan LR, Meade-Murphy G, Gilligan OM, Mykytiv V, Young PW, Cahill MR. Platelet hyperactivation in multiple myeloma is also evident in patients with premalignant monoclonal gammopathy of undetermined significance. Br J Haematol 2020; 192:322-332. [PMID: 32478420 DOI: 10.1111/bjh.16774] [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: 03/12/2020] [Accepted: 05/01/2020] [Indexed: 12/01/2022]
Abstract
Thrombotic events are common in patients with multiple myeloma (MM), smouldering myeloma (SM) and monoclonal gammopathy of undetermined significance (MGUS). Previous studies have indicated platelet hyperactivation as a feature of thrombotic risk in MM, but there is a dearth of data in MGUS. In the present study, multiparameter analysis of platelet activation and responsiveness was investigated by flow cytometry in patients with MGUS, SM/MM and healthy controls (HCs). The median platelet surface CD63 levels, annexin V and PAC-1 antibody (specific for activated integrin αIIbβ3) binding were significantly elevated in patients with MGUS versus the HCs. These markers were also elevated in SM/MM, but not significantly. In all, 74% of MGUS and 38% of SM/MM patients had one or more elevated marker of platelet activation, compared to 19% of the HCs. Marker-specific hyporesponsiveness of platelets to agonist [adenosine diphosphate (ADP), thrombin receptor-activating peptide 6] stimulation in vitro was observed, with significantly reduced surface levels of P-selectin in response to ADP in patients with MGUS. Platelet-leucocyte aggregates were not altered in patients, while platelet-associated immunoglobulins were elevated in a subset of patients. Overall, we found that platelet hyperactivation is prevalent in both MGUS and SM/MM patients and is potentially related to hyporesponsiveness. These observations suggest that further investigation of the predictive and prognostic value of platelet hyperactivation in such patients is warranted.
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Affiliation(s)
- Leanne R O'Sullivan
- School of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
| | | | | | - Vitaliy Mykytiv
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Paul W Young
- School of Biochemistry and Cell Biology, University College Cork, Cork, Ireland
| | - Mary R Cahill
- Department of Haematology, Cork University Hospital, Cork, Ireland.,CancerResearch@UCC, University College Cork, Cork, Ireland
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15
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Multiple Myeloma Mimicking a Small Vessel Vasculitis Presentation. Case Rep Rheumatol 2020; 2020:9146842. [PMID: 32099712 PMCID: PMC7037530 DOI: 10.1155/2020/9146842] [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: 11/08/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/24/2022] Open
Abstract
Multiple myeloma can have different clinical manifestations, and not all patients present with classic CRAB component. We describe a 46-year-old woman admitted to our hospital with a complaint of a bluish-to-black discoloration of the second toe that was rapidly progressive and acute kidney injury. We documented a Kappa light chain monoclonal gammopathy, increased presence of plasmacytes in bone marrow aspiration, and multiple lytic bone lesions, which led to a diagnosis of multiple myeloma. Although multiple myeloma presenting with blue finger syndrome is uncommon, it must always be considered as a differential diagnosis with this clinical finding.
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16
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de Rooij E, Verheul R, de Vreede M, de Jong Y. Cytomegalovirus infection with pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance: a case and systematic review. BMJ Case Rep 2019; 12:e226448. [PMID: 30837233 PMCID: PMC6424189 DOI: 10.1136/bcr-2018-226448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2018] [Indexed: 02/01/2023] Open
Abstract
A 62-year-old immunocompetent woman was admitted with cytomegalovirus (CMV) infection, pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance (MGUS). Anticoagulation therapy was started. Two months later, seroconversion of CMV IgM to IgG was observed, while the monoclonal protein was no longer detectable. This suggests a relationship between acute CMV infection, transient MGUS and thrombosis. In accordance with current best practice guidelines for provoked venous thromboembolism (VTE), anticoagulation therapy could be discontinued after 3 months instead of 6 for unprovoked VTE, thereby reducing unnecessary time at risk of bleeding complications. While the relationships between CMV and both MGUS and thrombosis have been described independently, we are first to describe these three conditions occurring simultaneously.Furthermore, we provide a systematic review on the relation between CMV, MGUS and thrombosis.
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Affiliation(s)
- Esther de Rooij
- Department of Internal Medicine, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Rolf Verheul
- Department of Clinical Chemistry and Laboratory Medicine, LabWest, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Mariëlle de Vreede
- Department of Haematology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Ype de Jong
- Department of Internal Medicine, Haaglanden Medical Center, Den Haag, The Netherlands
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17
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Park H, Kim JW, Youk J, Koh Y, Lee JO, Kim KH, Bang SM, Kim I, Park S, Yoon SS. Serum Free Light Chain Difference and β 2 Microglobulin Levels Are Risk Factors for Thromboembolic Events in Patients With AL Amyloidosis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:408-414. [DOI: 10.1016/j.clml.2018.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/03/2018] [Accepted: 03/09/2018] [Indexed: 11/29/2022]
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18
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Caimi G, Hopps E, Carlisi M, Montana M, Gallà E, Lo Presti R, Siragusa S. Hemorheological parameters in Monoclonal Gammopathy of Undetermined Significance (MGUS). Clin Hemorheol Microcirc 2018; 68:51-59. [DOI: 10.3233/ch-170289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- G. Caimi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - E. Hopps
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - M. Carlisi
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - M. Montana
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - E. Gallà
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
| | - R. Lo Presti
- Dipartimento di Scienze Psicologiche, Pedagogiche e della Formazione, Università di Palermo, Palermo, Italy
| | - S. Siragusa
- Dipartimento Biomedico di Medicina Interna e Specialistica, Università di Palermo, Palermo, Italy
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19
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Annibali O, Napolitano M, Avvisati G, Siragusa S. Incidence of venous thromboembolism and use of anticoagulation in hematological malignancies: Critical review of the literature. Crit Rev Oncol Hematol 2018; 124:41-50. [PMID: 29548485 DOI: 10.1016/j.critrevonc.2018.02.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 12/04/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022] Open
Abstract
Venous Thromboembolism (VTE) frequently complicates the course of hematologic malignancies (HM) and its incidence is similar to that observed in high-risk solid tumors. Despite that, pharmacologic prophylaxis and treatment of VTE in patients with HM is challenging, mainly because a severe thrombocytopenia frequently complicates the course of treatments or may be present since diagnosis, thus increasing the risk of bleeding. Therefore, in this setting, safe and effective methods of VTE prophylaxis and treatment have not been well defined and hematologists generally refer to guidelines produced for cancer patients that give indications on anticoagulation in patients with thrombocytopenia. In this review, besides to summarize the incidence and the available data on prophylaxis and treatment of VTE in HM, we give some advices on how to use antithrombotic drugs in patients with HM according to platelets count.
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Affiliation(s)
- Ombretta Annibali
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Mariasanta Napolitano
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy.
| | - Giuseppe Avvisati
- Hematology and Stem Cell Transplantation Unit, University Campus Bio-Medico, Italy
| | - Sergio Siragusa
- Hematology Unit, Reference Regional Center for Thrombosis and Haemostasis, University of Palermo, Italy
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20
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McShane CM, Murphy B, Lim KH, Anderson LA. Monoclonal gammopathy of undetermined significance as viewed by haematology healthcare professionals. Eur J Haematol 2018; 100:20-26. [PMID: 28885714 DOI: 10.1111/ejh.12962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the words and descriptions used by haematology healthcare professionals (HCPs) to describe monoclonal gammopathy of undetermined significance (MGUS) to their patients. METHODS A cross-sectional survey of haematology HCPs attending an annual haematology conference was undertaken. Content analysis was applied to the returned qualitative responses. RESULTS In total, 55 people, many of whom were doctors (n = 32; 58.2%), responded. The majority of respondents reported using simple terminology such as "abnormal protein" to describe MGUS to their patients. Some reported using analogies that the patient was more likely to be familiar with, such as comparing a paraprotein to the finding of a mole or lump. Education level, age and cognitive ability were cited as important factors in deciding how and whether information was relayed to patients. Many respondents supported frequent follow-up and the transfer of low-risk MGUS patients to primary care. However, several highlighted a lack of awareness and understanding of MGUS outside of haematology, particularly within primary care. Only 41.8% of respondents reported providing all of their patients with an information leaflet. CONCLUSIONS With an ageing population, it is important to consider management strategies for MGUS patients. Our findings will assist those in making these arrangements.
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Affiliation(s)
- Charlene M McShane
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Blain Murphy
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Kah Heng Lim
- Centre for Medical Education, School of Medicine, Dentistry & Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Lesley A Anderson
- Cancer Epidemiology and Health Services Research Group, Centre for Public Health, Queen's University Belfast, Belfast, UK
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21
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Wu XY, Yin YF, Teng JL, Zhang LW, Yang CD. IgMk paraprotein from gammopathy patient can bind to cardiolipin and interfere with coagulation assay: a case report. BMC Immunol 2017. [PMID: 28645246 PMCID: PMC5482953 DOI: 10.1186/s12865-017-0213-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The monoclonal gammopathies are a group of plasma-cell proliferative disorders characterized by the secretion of monoclonal immunoglobulin (M protein or paraprotein). Some rare cases have revealed the specific affinity of paraprotein as autoantibody. Here we report a patient with monoclonal gammopathy of undetermined significance (MGUS) accompanied by a remarkable increase of anticardiolipin antibody (aCL) and an extensively decreased coagulation factor activity, however, without any clinical signs of antiphospholipid syndrome (APS) and bleeding. Results Our further investigation indicated that IgMκ paraprotein of this patient possessed an antibody activity against phospholipids so as to bind to cardiolipin and interfere with coagulation assay in vitro. Conclusions This case might be indicative that an abnormality of coagulation tests, disturbed by IgMκ paraprotein, does not predict a risk of bleeding in this patient.
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Affiliation(s)
- Xin-Yao Wu
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 197 Ruijin Second Road, Huangpu District, Shanghai, 200025, China
| | - Yu-Feng Yin
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 197 Ruijin Second Road, Huangpu District, Shanghai, 200025, China
| | - Jia-Lin Teng
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 197 Ruijin Second Road, Huangpu District, Shanghai, 200025, China
| | - Li-Wei Zhang
- Department of Clinical Laboratory, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Cheng-de Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, No. 197 Ruijin Second Road, Huangpu District, Shanghai, 200025, China.
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22
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Crowley MP, Kevane B, O’Shea SI, Quinn S, Egan K, Gilligan OM, Ní. Áinle F. Plasma Thrombin Generation and Sensitivity to Activated Protein C Among Patients With Myeloma and Monoclonal Gammopathy of Undetermined Significance. Clin Appl Thromb Hemost 2016; 22:554-62. [DOI: 10.1177/1076029615625825] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The etiology of the prothrombotic state in myeloma has yet to be definitively characterized. Similarly, while recent evidence suggests that patients with monoclonal gammopathy of undetermined significance (MGUS) may also be at increased risk of thrombosis, the magnitude and the etiology of this risk have also yet to be defined. The present study aims to characterize patterns of plasma thrombin generation and sensitivity to the anticoagulant activity of activated protein C (APC) at the time of initial diagnosis of myeloma and in response to therapy in comparison to that observed among patients with MGUS and matched, healthy volunteers. Patients presenting with newly diagnosed/newly relapsed myeloma (n = 8), MGUS (n = 8), and matched healthy volunteers (n = 8) were recruited. Plasma thrombin generation was determined by calibrated automated thrombography. Peak thrombin generation was significantly higher in patients with myeloma (383.4 ± 33.4 nmol/L) and MGUS (353.4 ± 16.5 nmol/L) compared to healthy volunteers (276.7 ± 20.8 nmol/L; P < .05). In the presence of APC, endogenous thrombin potential was significantly lower in control plasma (228.6 ± 44.5 nmol/L × min) than in either myeloma (866.2 ± 241.3 nmol/L × min, P = .01) or MGUS plasma (627 ± 91.5 nmol/L × min, P = .003). Within the myeloma cohort, peak thrombin generation was significantly higher at diagnosis (353.2 ± 15.9 nmol/L) than following completion of the third cycle of therapy (282.1 ± 15.2 nmol/L; P < .005). Moreover, sensitivity to APC increased progressively with each cycle of chemotherapy. Further study of the etiology and evolving patterns of hypercoagulability among patients with these conditions is warranted and may have future implications for thromboprophylaxis strategies.
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Affiliation(s)
- Maeve P. Crowley
- Department of Haematology, Cork University Hospital, Cork, Ireland
- Clinical Research Facility, University College Cork, Ireland
- Maeve P. Crowley and Barry Kevane are joint first authors
| | - Barry Kevane
- Department of Haematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine & Medical Science, University College Dublin, Dublin, Ireland
- SPHERE Research Group, UCD Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
- Maeve P. Crowley and Barry Kevane are joint first authors
| | - Susan I. O’Shea
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Shane Quinn
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Karl Egan
- School of Medicine & Medical Science, University College Dublin, Dublin, Ireland
- SPHERE Research Group, UCD Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
| | | | - Fionnuala Ní. Áinle
- Department of Haematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine & Medical Science, University College Dublin, Dublin, Ireland
- SPHERE Research Group, UCD Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
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Kuderer NM, Culakova E, Lyman GH, Francis C, Falanga A, Khorana AA. A Validated Risk Score for Venous Thromboembolism Is Predictive of Cancer Progression and Mortality. Oncologist 2016; 21:861-7. [PMID: 27125754 DOI: 10.1634/theoncologist.2015-0361] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 02/01/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Retrospective studies have suggested an association between cancer-associated venous thromboembolism (VTE) and patient survival. We evaluated a previously validated VTE Clinical Risk Score in also predicting early mortality and cancer progression. METHODS A large, nationwide, prospective cohort study of adults with solid tumors or lymphoma initiating chemotherapy was conducted from 2002 to 2006 at 115 U.S. practice sites. Survival and cancer progression were estimated by the method of Kaplan and Meier. Multivariate analysis was based on Cox regression analysis adjusted for major prognostic factors including VTE itself. RESULTS Of 4,405 patients, 134 (3.0%) died and 330 (7.5%) experienced disease progression during the first 4 months of therapy (median follow-up 75 days). Patients deemed high risk (n = 540, 12.3%) by the Clinical Risk Score had a 120-day mortality rate of 12.7% (adjusted hazard ratio [aHR] 3.00, 95% confidence interval [CI] 1.4-6.3), and intermediate-risk patients (n = 2,665, 60.5%) had a mortality rate of 5.9% (aHR 2.3, 95% CI 1.2-4.4) compared with only 1.4% for low-risk patients (n = 1,200, 27.2%). At 120 days of follow-up, cancer progression occurred in 27.2% of high-risk patients (aHR 2.2, 95% CI 1.4-3.5) and 16.4% of intermediate-risk patients (aHR 1.9, 95% CI 1.3-2.7) compared with only 8.5% of low-risk patients (p < .0001). CONCLUSION The Clinical Risk Score, originally developed to predict the occurrence of VTE, is also predictive of early mortality and cancer progression during the first four cycles of outpatient chemotherapy, independent from other major prognostic factors including VTE itself. Ongoing and future studies will help determine the impact of VTE prophylaxis on survival. IMPLICATIONS FOR PRACTICE The risk of venous thromboembolism (VTE) is increased in patients receiving cancer chemotherapy. In this article, the authors demonstrate that a popular risk score for VTE in patients with cancer is also associated with the risk of early mortality in this setting. It is important that clinicians evaluate the risk of VTE in patients receiving cancer treatment and discuss the risk and associated symptoms of VTE with patients. Individuals at increased risk should be advised that VTE is a medical emergency and should be urgently diagnosed and appropriately treated to reduce the risk of serious and life-threatening complications.
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Affiliation(s)
| | - Eva Culakova
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Gary H Lyman
- University of Washington, Seattle, Washington, USA Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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25
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Franchini M. Thromboembolic risk in hematological malignancies. Clin Chem Lab Med 2016; 53:1139-47. [PMID: 25503466 DOI: 10.1515/cclm-2014-1010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 11/06/2014] [Indexed: 12/20/2022]
Abstract
There are a growing number of studies documenting that, similarly to patients with solid cancers, also patients with hematological malignancies (i.e., acute leukemia, lymphoproliferative and myeloproliferative neoplasms and plasma cell disorders) are at increased risk of thrombosis. The pathogenesis of the hypercoagulable state associated with hematological cancers is often multifactorial. Contributor factors include tumor cell-derived procoagulants, antineoplastic therapies, central venous catheters, concomitant infections and advanced age. In this narrative review, the epidemiology, pathogenesis and management of thrombosis in patients with hematological malignancies are reviewed.
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de Moreuil C, Ianotto JC, Eveillard JR, Carrier M, Delluc A. [Multiple myeloma and venous thrombosis. Which thromboprophylaxis should be given?]. Rev Med Interne 2016; 37:473-9. [PMID: 26833146 DOI: 10.1016/j.revmed.2015.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 11/24/2015] [Accepted: 12/29/2015] [Indexed: 01/06/2023]
Abstract
Multiple myeloma is a malignant plasma cells dyscrasia that mainly affects patients older than 65 years. These patients are at a higher risk for venous thromboembolism (VTE) because of cancer status, intrinsic risk factors, and exposure to prothrombotic therapies. The risk for VTE appears higher during the first months of myeloma treatment and decreases over time. Exposure to immunomodulatory drugs (IMIDs) such as thalidomide or lenalidomide in association with high doses of dexamethasone or anthracyclin-based chemotherapy is associated with a four-fold increased risk for VTE. Low-dose aspirin, preventive-dose of low molecular weight heparin (LMWH) or vitamin K antagonists were tested for primary prevention of VTE in myeloma patients receiving chemotherapy. The International Myeloma Working Group (IMWG) suggests stratifying VTE risk to decide which patients should receive VTE prevention. Then, the IMWG suggests giving low-dose aspirin to low VTE risk patients and LMWH or vitamin K antagonists to patients at high risk for VTE. For daily practice, it seems reasonable to start preventive doses of LMWH for 3 to 6 months in ambulatory myeloma patients receiving combined therapy with IMID and in all myeloma patients admitted to hospital.
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Affiliation(s)
- C de Moreuil
- EA 3878 (GETBO), département de médecine interne et de pneumologie, hôpital de la Cavale-Blanche, CHRU de Brest, 29609 Brest cedex, France
| | - J-C Ianotto
- EA 3878 (GETBO), département de médecine interne et de pneumologie, hôpital de la Cavale-Blanche, CHRU de Brest, 29609 Brest cedex, France; Service d'hématologie clinique, institut de cancéro-hématologie, hôpital Morvan, CHRU de Brest, 29609 Brest cedex, France
| | - J-R Eveillard
- Service d'hématologie clinique, institut de cancéro-hématologie, hôpital Morvan, CHRU de Brest, 29609 Brest cedex, France
| | - M Carrier
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, 501, Smyth Road, K1H 8 L6 Ottawa, Ontario, Canada
| | - A Delluc
- EA 3878 (GETBO), département de médecine interne et de pneumologie, hôpital de la Cavale-Blanche, CHRU de Brest, 29609 Brest cedex, France.
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27
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Venous thromboembolism in patients with chronic lymphocytic leukemia. Thromb Res 2015; 136:1082-6. [DOI: 10.1016/j.thromres.2015.05.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/04/2015] [Accepted: 05/12/2015] [Indexed: 11/24/2022]
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28
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Goebel TE, Schiltz NK, Woodside KJ, Pillai AC, Caimi PF, Lazarus HM, Koroukian SM, Campagnaro EL. Neoplastic and non-neoplastic complications of solid organ transplantation in patients with preexisting monoclonal gammopathy of undetermined significance. Clin Transplant 2015; 29:851-7. [PMID: 26194021 DOI: 10.1111/ctr.12595] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 01/27/2023]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) occurs in 3-7% of the elderly population, with higher prevalence in renal failure patients, and is associated with a 25-fold increased lifetime risk for plasma cell myeloma (PCM), also known as multiple myeloma. Using the California State Inpatient, Emergency Department, and Ambulatory Surgery Databases components of the Healthcare Cost and Utilization Project (HCUP), we sought to determine whether patients with MGUS who undergo solid organ allograft (n = 22,062) are at increased adjusted relative risk (aRR) for hematologic malignancy and other complications. Among solid organ transplant patients, patients with preexisting MGUS had higher aRR of PCM (aRR 19.46; 95% CI 7.05, 53.73; p < 0.001), venous thromboembolic events (aRR 1.66; 95% CI 1.15, 2.41; p = 0.007), and infection (aRR 1.24; 95% CI 1.06, 1.45; p = 0.007). However, when comparing MGUS patients with and without solid organ transplant, there was decreased aRR for PCM with transplant (aRR 0.34; 95% CI 0.13, 0.88; p = 0.027), and increased venous thromboembolic events (aRR 2.33; 95% CI 1.58, 3.44; p < 0.001) and infectious risks (aRR 1.44; 95% CI 1.23, 1.70; p < 0.001). While MGUS increased the risk of PCM overall following solid organ transplantation, there was lower risk of PCM development compared to MGUS patients who did not receive a transplant. MGUS should not preclude solid organ transplant.
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Affiliation(s)
- Teresa E Goebel
- Division of Hematology & Oncology, Department of Internal Medicine, Case Comprehensive Cancer Center & University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Nicholas K Schiltz
- Department of Epidemiology & Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Cleveland, OH, USA
| | - Kenneth J Woodside
- Section of Transplant Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aiswarya Chandran Pillai
- Department of Epidemiology & Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Cleveland, OH, USA
| | - Paolo F Caimi
- Division of Hematology & Oncology, Department of Internal Medicine, Case Comprehensive Cancer Center & University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Hillard M Lazarus
- Division of Hematology & Oncology, Department of Internal Medicine, Case Comprehensive Cancer Center & University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - Siran M Koroukian
- Department of Epidemiology & Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Cleveland, OH, USA
| | - Erica L Campagnaro
- Division of Hematology & Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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29
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Egan K, Cooke N, Dunne E, Murphy P, Quinn J, Kenny D. Platelet hyporeactivity in active myeloma. Thromb Res 2014; 134:747-9. [DOI: 10.1016/j.thromres.2014.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 06/24/2014] [Accepted: 06/26/2014] [Indexed: 10/25/2022]
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Colombo R, Gallipoli P, Castelli R. Thrombosis and hemostatic abnormalities in hematological malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:441-50. [PMID: 25018062 DOI: 10.1016/j.clml.2014.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 05/19/2014] [Indexed: 01/19/2023]
Abstract
There is a paucity of data that pertain to thrombosis in patients with hematological malignancies. Recent studies showed that patients with lymphoma, multiple myeloma, and acute leukemia have an increased thrombotic risk, particularly at the time of diagnosis and during chemotherapy. We searched the PubMed database for articles on thromboembolic complications in patients with hematological malignancies published between 1996 and 2013. The incidence of thrombotic events is variable, and is influenced by the type and the stage of hematological malignancy, the antitumor therapy, and the use of central venous devices. The pathogenesis of thromboembolic disease in hematological malignancies is multifactorial. Tumor cell-derived procoagulant, fibrinolytic, or proteolytic factors, and inflammatory cytokines affect clotting activation, and chemotherapy and immunomodulatory drugs increase the thrombotic risk in patients with lymphoma, acute leukemia, and multiple myeloma. Infections might also contribute to the pathogenesis of the thromboembolic complications: endotoxins from gram-negative bacteria induce the release of tissue factor, tumor necrosis factor and interleukin-1b, and gram-positive organisms can release bacterial mucopolysaccharides that directly activate factor XII. In the setting of plasma cell dyscrasias, hyperviscosity, decreased fibrinolysis, procoagulant autoantibody production, inflammatory cytokines, acquired activated protein C resistance, and the prothrombotic effects of antimyeloma agents might be the cause of thromboembolic complications. Anticoagulant therapy is very complicated because of high risk of hemorrhage. Therefore, an accurate estimate of a patient's thrombotic risk is essential to allow physicians to target thromboprophylaxis in high-risk patients.
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Affiliation(s)
- Riccardo Colombo
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Gallipoli
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Haematology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.
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31
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van de Donk NWCJ, Palumbo A, Johnsen HE, Engelhardt M, Gay F, Gregersen H, Hajek R, Kleber M, Ludwig H, Morgan G, Musto P, Plesner T, Sezer O, Terpos E, Waage A, Zweegman S, Einsele H, Sonneveld P, Lokhorst HM. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99:984-96. [PMID: 24658815 PMCID: PMC4040895 DOI: 10.3324/haematol.2013.100552] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/14/2014] [Indexed: 12/18/2022] Open
Abstract
Monoclonal gammopathy of undetermined significance is one of the most common pre-malignant disorders. IgG and IgA monoclonal gammopathy of undetermined significance are precursor conditions of multiple myeloma; light-chain monoclonal gammopathy of undetermined significance of light-chain multiple myeloma; and IgM monoclonal gammopathy of undetermined significance of Waldenström's macroglobulinemia and other lymphoproliferative disorders. Clonal burden, as determined by bone marrow plasma cell percentage or M-protein level, as well as biological characteristics, including heavy chain isotype and light chain production, are helpful in predicting risk of progression of monoclonal gammopathy of undetermined significance to symptomatic disease. Furthermore, alterations in the bone marrow microenvironment of monoclonal gammopathy of undetermined significance patients result in an increased risk of venous and arterial thrombosis, infections, osteoporosis, and bone fractures. In addition, the small clone may occasionally be responsible for severe organ damage through the production of a monoclonal protein that has autoantibody activity or deposits in tissues. These disorders are rare and often require therapy directed at eradication of the underlying plasma cell or lymphoplasmacytic clone. In this review, we provide an overview of the clinical relevance of monoclonal gammopathy of undetermined significance. We also give general recommendations of how to diagnose and manage patients with monoclonal gammopathy of undetermined significance.
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Affiliation(s)
| | - Antonio Palumbo
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Hans Erik Johnsen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Francesca Gay
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Henrik Gregersen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Roman Hajek
- Department of Haemato-oncology, University Hospital Ostrava and Faculty of Medicine, Czech Republic
| | - Martina Kleber
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Heinz Ludwig
- Department of Medicine I, Wilhelminenspital Wien, Austria
| | - Gareth Morgan
- Institute of Cancer Research, Royal Marsden Hospital, London, UK
| | - Pellegrino Musto
- Scientific Direction, Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture, Italy
| | | | - Orhan Sezer
- Department of Hematology, Memorial Hospital, Istanbul, Turkey
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Greece
| | - Anders Waage
- Department of Hematology, St. Olavs Hospital, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hermann Einsele
- Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henk M Lokhorst
- Department of Hematology, University Medical Center Utrecht, The Netherlands
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Boyle EM, Fouquet G, Manier S, Gauthier J, Noel MP, Borie C, Facon T, Elalamy I, Leleu X. Immunomodulator drug-based therapy in myeloma and the occurrence of thrombosis. Expert Rev Hematol 2014; 5:617-26; quiz 627. [DOI: 10.1586/ehm.12.52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
Multiple myeloma, as with other malignancies, has been associated with the development of venous thromboembolic events. Chemotherapy or steroids in combination with antiangiogenic agents can further enhance this risk. The identification of measurable factors associated with this prothrombotic state could help in the selection of patients who need antithrombotic prophylaxis. Malignancy-associated thrombophilic state, paraprotein-specific mechanisms and treatment-induced changes can explain the high rate of thrombosis in this cancer population. While the release of inflammatory cytokines induces high levels of factor VIII, von Willebrand factor and downregulate the protein C system, elevated plasma immunoglobulin can impair fibrinolysis. Strategies of thromboprophylaxis with low molecular weight heparin, warfarin or aspirin in patients treated with thalidomide/chemotherapy or lenalidomide and dexamethasone have shown efficacy. Early data indicate that the effect of low molecular weight heparin on multiple myeloma is not confined to the anticoagulant effect but could extend to survival; a similar positive trend in overall survival has also been reported in patients treated with aspirin.
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Affiliation(s)
- Maurizio Zangari
- Myeloma Institute, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Slot 776, Little Rock, Arkansas 72205, USA.
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34
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Caers J, Vekemans MC, Bries G, Beel K, Delrieu V, Deweweire A, Demuynck H, De Prijck B, De Samblanx H, Kentos A, Meuleman N, Mineur P, Offner F, Vande Broek I, Van Droogenbroeck J, Vande Velde A, Wu KL, Delforge M, Schots R, Doyen C. Diagnosis and follow-up of monoclonal gammopathies of undetermined significance; information for referring physicians. Ann Med 2013; 45:413-22. [PMID: 23767978 DOI: 10.3109/07853890.2013.801562] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The prevalence of monoclonal gammopathy of undetermined significance (MGUS) is generally estimated at 3.4% in the general population over 50 years, and its incidence increases with age. MGUS represents a preneoplastic entity that can transform into multiple myeloma or other lymphoproliferative disorders. The risk of malignant transformation is estimated at 1% per year and persists over time. Predictors of malignant transformation have been identified such as the heavy chain isotype, The level of monoclonal proteins, increasing levels of the monoclonal component during the first years off follow-up, the percentage of bone marrow plasmocytosis, the dosage of serum free light chains, the presence of immunophenotypically abnormal plasma cells, aneuploidy, and the presence of circulating plasma cells. Prognostic scores that combine certain of these factors have been proposed and allow the identification of high-risk patients. Their use could assist in tailoring the care for each patient, based on his/her risk profile.
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35
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Ali AM, Mirrakhimov AE. Monoclonal gammopathy of undetermined significance associated with blue finger syndrome. BMJ Case Rep 2013; 2013:bcr-2012-007966. [PMID: 23291824 DOI: 10.1136/bcr-2012-007966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
An 86-year-old Caucasian woman with a medical history of monoclonal gammopathy of undetermined significance (MGUS) was admitted to the hospital with a chief complaint of sudden onset of bluish discolouration of the fifth left hand digit. On a physical examination, cyanosis of the fifth digit of the left hand was noticed with decreased capillary fill but no ulcers. The patient had no tenderness on palpation. Pulses were palpable over the radial arteries bilaterally. Patients with MGUS may be at increased risk of thromboembolic disease. A clear explanation for this association in these patients is not currently known. This case report highlights the association between MGUS and thromboembolic events, particularly blue finger syndrome.
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Affiliation(s)
- Alaa M Ali
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
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36
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Za T, De Stefano V, Rossi E, Petrucci MT, Andriani A, Annino L, Cimino G, Caravita T, Pisani F, Ciminello A, Torelli F, Villivà N, Bongarzoni V, Rago A, Betti S, Levi A, Felici S, Gentilini F, Calabrese E, Leone G. Arterial and venous thrombosis in patients with monoclonal gammopathy of undetermined significance: incidence and risk factors in a cohort of 1491 patients. Br J Haematol 2012; 160:673-9. [PMID: 23240810 DOI: 10.1111/bjh.12168] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/05/2012] [Indexed: 12/21/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) has been associated with an increased risk of thrombosis. We carried out a retrospective multicentre cohort study on 1491 patients with MGUS. In 49 patients (3.3%) MGUS was diagnosed after a thrombotic event. Follow-up details for a period of at least 12 months after diagnosis of MGUS were obtained in 1238 patients who had no recent history of thrombosis (<2 years) prior to diagnosis, for a total of 7334 years. During the follow-up, 33 of 1238 patients (2.7%) experienced thrombosis, with an incidence of 2.5 arterial events and 1.9 venous events per 1000 patient-years. Multivariate analysis showed increased risks of arterial thrombosis in patients with cardiovascular risk factors [hazard ratio (HR) 4.92, 95%confidence interval (CI) 1.42-17.04], and of venous thrombosis in patients with a serum monoclonal (M)-protein level >16 g/l at diagnosis (HR 3.08, 95%CI 1.01-9.36). No thrombosis was recorded in patients who developed multiple myeloma (n = 50) or other neoplastic diseases (n = 21). The incidence of arterial or venous thrombosis in patients with MGUS did not increase relative to that reported in the general population for similarly aged members. Finally, the risk of venous thrombosis did increase when the M-protein concentration exceeded >16 g/l.
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Affiliation(s)
- Tommaso Za
- Institute of Haematology, Catholic University, Rome, Italy
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38
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Elice F, Rodeghiero F. Hematologic malignancies and thrombosis. Thromb Res 2011; 129:360-6. [PMID: 22197450 DOI: 10.1016/j.thromres.2011.11.034] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 11/17/2011] [Accepted: 11/20/2011] [Indexed: 12/22/2022]
Abstract
Patients with hematologic malignancies have an increased risk of venous thromboembolism (VTE), particularly at diagnosis and during the treatment with chemotherapy, asparaginase or immunomodulatory drugs (IMiDs). A disease-dependent hypercoagulable condition associated with other risk factors like drugs, central venous catheter (CVC), immobility and infections are responsible for this high VTE rate. Thrombotic complications have a significant impact on morbidity and in some cases also on mortality of patients with onco-hematologic diseases, therefore thromboprophylaxis to prevent VTE in this setting is needed. However, thrombocytopenia and hemorrhagic complications pone many difficulties in the management of an anticoagulant or antiaggregant treatment in these patients. Recommendations from current guidelines are limited to multiple myeloma patients treated with thalidomide or lenalidomide associated with dexamethasone or chemotherapy, but hematological clinical departments should implement a policy for prevention and treatment of thromboembolic complications in hematologic malignancies.
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Affiliation(s)
- F Elice
- Department of Cell Therapy and Hematology, San Bortolo Hospital, Vicenza, Italy
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39
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Thrombotic complications in multiple myeloma: a report of three cases and review of the literature. J Thromb Thrombolysis 2011; 33:197-201. [DOI: 10.1007/s11239-011-0636-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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40
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Kristinsson SY, Björkholm M, Schulman S, Landgren O. Hypercoagulability in Multiple Myeloma and Its Precursor State, Monoclonal Gammopathy of Undetermined Significance. Semin Hematol 2011; 48:46-54. [DOI: 10.1053/j.seminhematol.2010.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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41
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Gregersen H, Nørgaard M, Severinsen MT, Engebjerg MC, Jensen P, Sørensen HT. Monoclonal gammopathy of undetermined significance and risk of venous thromboembolism. Eur J Haematol 2010; 86:129-34. [PMID: 20942842 DOI: 10.1111/j.1600-0609.2010.01539.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with multiple myeloma are at increased risk of venous thromboembolism (VTE), but little information is available on VTE risk in patients with the precursor condition monoclonal gammopathy of undetermined significance (MGUS). OBJECTIVE To evaluate the risk of VTE and its impact on mortality in patients with MGUS. PATIENTS AND METHODS We identified 1610 patients with MGUS and no prior diagnosis of VTE during the 1978-2005 period in North Jutland County, Denmark. We used the Danish Central Population Registry to select 16,100 general population comparison cohort members with no prior VTE diagnosis, matched with the MGUS patients by age, sex, and comorbidity. Follow-up data on VTE incidence in the two groups were obtained from the Danish National Patient Registry covering all Danish hospitals. Time-varying Cox regression analysis was used to compute the incidence rate ratio (IRR) of VTE and the mortality rate ratio (MRR) for MGUS patients who developed VTE compared to MGUS patients without VTE. RESULTS In the MGUS cohort, 50 VTE events were identified during 12,594 person-years (PY) of follow-up, corresponding to an incidence rate of 4.0 VTEs/1000 PY. The IRR for VTE among MGUS patients compared to the comparison cohort was 1.37 (95% confidence interval (CI): 1.00-1.88). Of the 50 MGUS patients with VTE, one was later diagnosed with malignant transformation. The adjusted MRR for MGUS patients with VTE compared to MGUS patients without VTE was 1.94 (95% CI: 1.36-2.77). CONCLUSIONS MGUS is a risk factor for VTE, and VTE is a marker for increased mortality among MGUS patients.
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Affiliation(s)
- Henrik Gregersen
- Department of Haematology, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
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42
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Uaprasert N, Voorhees PM, Mackman N, Key NS. Venous thromboembolism in multiple myeloma: Current perspectives in pathogenesis. Eur J Cancer 2010; 46:1790-9. [PMID: 20385482 DOI: 10.1016/j.ejca.2010.03.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Revised: 03/01/2010] [Accepted: 03/11/2010] [Indexed: 12/11/2022]
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43
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Berenson JR, Anderson KC, Audell RA, Boccia RV, Coleman M, Dimopoulos MA, Drake MT, Fonseca R, Harousseau JL, Joshua D, Lonial S, Niesvizky R, Palumbo A, Roodman GD, San-Miguel JF, Singhal S, Weber DM, Zangari M, Wirtschafter E, Yellin O, Kyle RA. Monoclonal gammopathy of undetermined significance: a consensus statement. Br J Haematol 2010; 150:28-38. [PMID: 20507313 DOI: 10.1111/j.1365-2141.2010.08207.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
On February 25, 2009, a panel of international experts on plasma cell dyscrasia and skeletal disease met to discuss monoclonal gammopathy of undetermined significance (MGUS). This non-malignant B-cell disorder is the most common plasma cell dyscrasia and is associated with an increased risk of developing serious B-cell disorders. Individuals with MGUS also have an increased risk of osteoporosis and osteopenia associated with an increased likelihood of developing fractures especially in the vertebral column, peripheral neuropathy and thromboembolic events. The goal of the meeting was to develop a consensus statement regarding the appropriate tests to screen, evaluate and follow-up patients with MGUS. The panel also addressed the identification and treatment of MGUS-related skeletal problems, thromboembolic events and neurological complications. The following consensus statement outlines the conclusions and marks the first time that a consensus statement for the screening and treatment of MGUS has been clearly stated.
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Affiliation(s)
- James R Berenson
- Institute for Myeloma & Bone Cancer Research, West Hollywood, CA 90069, USA.
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Wun T, White RH. Venous thromboembolism in patients with acute leukemia, lymphoma, and multiple myeloma. Thromb Res 2010; 125 Suppl 2:S96-102. [DOI: 10.1016/s0049-3848(10)70024-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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45
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Arterial and venous thrombosis in monoclonal gammopathy of undetermined significance and multiple myeloma: a population-based study. Blood 2010; 115:4991-8. [PMID: 20299513 DOI: 10.1182/blood-2009-11-252072] [Citation(s) in RCA: 178] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Patients with multiple myeloma (MM) have an increased risk of venous thrombosis. Interestingly, excess risk of venous thromboembolism has been observed among patients with monoclonal gammopathy of undetermined significance (MGUS). Using population-based data from Sweden, we assessed the risks of venous and arterial thrombosis in 18,627 MM and 5326 MGUS patients diagnosed from 1958 to 2006, compared with 70,991 and 20,161 matched controls, respectively. At 1, 5, and 10 years after MM diagnosis, there was an increased risk of venous thrombosis: hazard ratios (95% confidence intervals) were 7.5 (6.4-8.9), 4.6 (4.1-5.1), and 4.1 (3.8-4.5), respectively. The corresponding results for arterial thrombosis were 1.9 (1.8-2.1), 1.5 (1.4-1.6), and 1.5 (1.4-1.5). At 1, 5, and 10 years after MGUS diagnosis, hazard ratios were 3.4 (2.5-4.6), 2.1 (1.7-2.5), and 2.1 (1.8-2.4) for venous thrombosis. The corresponding risks for arterial thrombosis were 1.7 (1.5-1.9), 1.3 (1.2-1.4), and 1.3 (1.3-1.4). IgG/IgA (but not IgM) MGUS patients had increased risks for venous and arterial thrombosis. Risks for thrombosis did not vary by M-protein concentration (> 10.0 g/L or < 10.0 g/L) at diagnosis. MGUS patients with (vs without) thrombosis had no excess risk of MM or Waldenström macroglobulinemia. Our findings are of relevance for future studies and for improvement of thrombosis prophylaxis strategies.
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46
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Madan S, Greipp PR. The incidental monoclonal protein: Current approach to management of monoclonal gammopathy of undetermined significance (MGUS). Blood Rev 2009; 23:257-65. [DOI: 10.1016/j.blre.2009.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Decaux O, Laurat E, Perlat A, Cazalets C, Jego P, Grosbois B. Systemic manifestations of monoclonal gammopathy. Eur J Intern Med 2009; 20:457-61. [PMID: 19712843 DOI: 10.1016/j.ejim.2009.01.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Accepted: 01/04/2009] [Indexed: 12/13/2022]
Abstract
Systemic manifestations of monoclonal gammopathies (MG) are rare but extremely varied. This general review focuses on the hyperviscosity syndrome, neurological disorders, skin changes, the POEMS syndrome, and biological manifestations, with the exception of amyloidosis AL and cryoglobulinemia. The hyperviscosity syndrome usually involves a combination of general, hemorrhagic, ocular and central neurological disorders. The principal neurological manifestations are peripheral neuropathies, mainly due to IgM with anti-MAG activity. Skin disorders include overload dermatoses (xanthomatosis, mucinosis), neutrophilic dermatosis, urticaria, edema and the AESOP syndrome. The POEMS syndrome classically consists of polyneuropathy, organomegaly, endocrinopathy, monoclonal plasmocyte proliferation, and cutaneous manifestations. MG interference with assay methods can lead to false hyponatremia, hypoglycemia, hyperbilirubinemia, hypercalcemia and hypertransferrinemia. These systemic manifestations can reveal classical MG-related disorders such as monoclonal gammopathy of undetermined significance (MGUS), solitary plasmocytoma, multiple myeloma, and Waldenstrom's disease. They are due either to the chemicophysical properties of the monoclonal immunoglobulin, or to its antibody activity (especially against autoantigens), with potential therapeutic implications.
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Affiliation(s)
- Olivier Decaux
- Service de Médecine Interne, Hôpital Sud, CHU, 16 boulevard de Bulgarie, 35 203 Rennes, France
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Bird J, Behrens J, Westin J, Turesson I, Drayson M, Beetham R, D'Sa S, Soutar R, Waage A, Gulbrandsen N, Gregersen H, Low E. UK Myeloma Forum (UKMF) and Nordic Myeloma Study Group (NMSG): guidelines for the investigation of newly detected M-proteins and the management of monoclonal gammopathy of undetermined significance (MGUS). Br J Haematol 2009; 147:22-42. [PMID: 19673884 DOI: 10.1111/j.1365-2141.2009.07807.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jenny Bird
- Avon Haematology Unit, Bristol Haematology and Oncology Centre, Bristol, UK.
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49
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Incidence and prophylaxis of venous thromboembolic events in multiple myeloma patients receiving immunomodulatory therapy. Thromb Res 2009; 123:679-86. [PMID: 18992924 DOI: 10.1016/j.thromres.2008.09.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Revised: 09/21/2008] [Accepted: 09/28/2008] [Indexed: 12/21/2022]
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50
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Connolly GC, Khorana AA. Risk stratification for cancer-associated venous thromboembolism. Best Pract Res Clin Haematol 2009; 22:35-47. [DOI: 10.1016/j.beha.2008.12.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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