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Maqbool S, Baloch MF, Khan MAK, Khalid A, Naimat K. Autologous hematopoietic stem cell transplantation conditioning regimens and chimeric antigen receptor T cell therapy in various diseases. World J Transplant 2024; 14:87532. [PMID: 38576761 PMCID: PMC10989471 DOI: 10.5500/wjt.v14.i1.87532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/21/2023] [Accepted: 01/08/2024] [Indexed: 03/15/2024] Open
Abstract
Conditioning regimens employed in autologous stem cell transplantation have been proven useful in various hematological disorders and underlying malig nancies; however, despite being efficacious in various instances, negative consequences have also been recorded. Multiple conditioning regimens were extracted from various literature searches from databases like PubMed, Google scholar, EMBASE, and Cochrane. Conditioning regimens for each disease were compared by using various end points such as overall survival (OS), progression free survival (PFS), and leukemia free survival (LFS). Variables were presented on graphs and analyzed to conclude a more efficacious conditioning regimen. In multiple myeloma, the most effective regimen was high dose melphalan (MEL) given at a dose of 200/mg/m2. The comparative results of acute myeloid leukemia were presented and the regimens that proved to be at an admirable position were busulfan (BU) + MEL regarding OS and BU + VP16 regarding LFS. In case of acute lymphoblastic leukemia (ALL), BU, fludarabine, and etoposide (BuFluVP) conferred good disease control not only with a paramount improvement in survival rate but also low risk of recurrence. However, for ALL, chimeric antigen receptor (CAR) T cell therapy was preferred in the context of better OS and LFS. With respect to Hodgkin's lymphoma, mitoxantrone (MITO)/MEL overtook carmustine, VP16, cytarabine, and MEL in view of PFS and vice versa regarding OS. Non-Hodgkin's lymphoma patients were administered MITO (60 mg/m2) and MEL (180 mg/m2) which showed promising results. Lastly, amyloidosis was considered, and the regimen that proved to be competent was MEL 200 (200 mg/m2). This review article demonstrates a comparison between various conditioning regimens employed in different diseases.
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Affiliation(s)
- Shahzaib Maqbool
- Department of Medicine, Holy Family Hospital, Rawalpindi 46000, Pakistan
| | - Maryam Farhan Baloch
- Department of Community Medicine, Allama Iqbal Medical College, Lahore 45000, Pakistan
| | | | - Azeem Khalid
- Department of Medicine, Allama lqbal Medical College, Lahore 45000, Pakistan
| | - Kiran Naimat
- Department of MedicineLiaquat University of Medical and Health Sciences, Karachi 43000, Pakistan
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2
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Alnasser SM, Alharbi KS, Almutairy AF, Almutairi SM, Alolayan AM. Autologous Stem Cell Transplant in Hodgkin's and Non-Hodgkin's Lymphoma, Multiple Myeloma, and AL Amyloidosis. Cells 2023; 12:2855. [PMID: 38132175 PMCID: PMC10741865 DOI: 10.3390/cells12242855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Human body cells are stem cell (SC) derivatives originating from bone marrow. Their special characteristics include their capacity to support the formation and self-repair of the cells. Cancer cells multiply uncontrollably and invade healthy tissues, making stem cell transplants a viable option for cancer patients undergoing high-dose chemotherapy (HDC). When chemotherapy is used at very high doses to eradicate all cancer cells from aggressive tumors, blood-forming cells and leukocytes are either completely or partially destroyed. Autologous stem cell transplantation (ASCT) is necessary for patients in those circumstances. The patients who undergo autologous transplants receive their own stem cells (SCs). The transplanted stem cells first come into contact with the bone marrow and then undergo engraftment, before differentiating into blood cells. ASCT is one of the most significant and innovative strategies for treating diseases. Here we focus on the treatment of Hodgkin's lymphoma, non-Hodgkin's lymphoma, multiple myeloma, and AL amyloidosis, using ASCT. This review provides a comprehensive picture of the effectiveness and the safety of ASCT as a therapeutic approach for these diseases, based on the currently available evidence.
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Affiliation(s)
- Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Khalid Saad Alharbi
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Ali F. Almutairy
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
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3
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Chakraborty R, Milani P, Palladini G, Gertz M. Role of autologous haematopoietic cell transplantation in the treatment of systemic light chain amyloidosis in the era of anti-CD38 monoclonal antibodies. Lancet Haematol 2023; 10:e936-e940. [PMID: 37802087 DOI: 10.1016/s2352-3026(23)00175-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/03/2023] [Accepted: 06/12/2023] [Indexed: 10/08/2023]
Abstract
The primary goal of the initial treatment in systemic light chain amyloidosis is to obtain a rapid and profound haematological response as safely as possible, coupled with supportive care by a multidisciplinary team. The treatment landscape has evolved with the introduction of highly effective therapies targeting the plasma cell clones, which can attain high rates of haematological complete response with minimal treatment-related morbidity and mortality. Consequently, the role of high-dose melphalan followed by autologous haematopoietic cell transplantation (HDM-AHCT) is being analysed, particularly considering the absence of randomised controlled trial data supporting its superiority over standard-dose therapies in systemic light chain amyloidosis treatment. In this Viewpoint, we will explore the role of HDM-AHCT in the management of patients with systemic light chain amyloidosis who are eligible for transplantation, and the unresolved questions surrounding HDM-AHCT use as both front-line and salvage therapy.
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Affiliation(s)
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Department of Molecular Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Department of Molecular Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Morie Gertz
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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4
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Wali E, Gruca M, Singulane C, Cotella J, Guile B, Johnson R, Mor-Avi V, Addetia K, Lang RM. How Often Does Apical Sparing of Longitudinal Strain Indicate the Presence of Cardiac Amyloidosis? Am J Cardiol 2023; 202:12-16. [PMID: 37413701 DOI: 10.1016/j.amjcard.2023.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
Echocardiographic diagnosis of cardiac amyloidosis (CA) is frequently suggested by the presence of a left ventricular (LV) apical sparing pattern (ASP) on longitudinal strain (LS) assessment, the so-called "cherry on top" pattern, defined by strain magnitude preserved exclusively at the apex. However, it is unclear how frequently this strain pattern truly represents CA. This study aimed to evaluate the predictive value of ASP in the diagnosis of CA. We retrospectively identified consecutive adult patients who had the following studies performed within an 18-month period: (1) transthoracic echocardiogram and (2) either (a) cardiac magnetic resonance imaging, (b) Technetium-Pyrophosphate (PYP) imaging, or (c) endomyocardial biopsy. LS was retrospectively measured in the apical 4-, 3-, and 2-chamber views in patients who had adequate noncontrast images (n = 466). An apical sparing ratio (ASR) was calculated as (average apical strain)/[(average basal strain) + (average midventricular strain)]. Patients with ASR ≥1 were evaluated for the presence/absence of CA, using established criteria. Basic LV parameters were also measured. A total of 33 patients (7.1%) had ASP. Nine of these patients (27%) had "confirmed" CA, 2 (6.1%) "highly probable" CA, 1 (3.0%) "possible" CA, and 21 (64%) no evidence of CA. When comparing patients with and without confirmed CA, there were no significant differences in ASR, average global LS, ejection fraction, or LV mass. Patients with confirmed CA were older (76 ± 9 vs 59 ± 18 years, p = 0.01) and had thicker posterior wall (15 ± 3 vs 11 ± 3 mm, p = 0.004) with a trend toward thicker septal wall (15 ± 2 vs 12 ± 4 mm, p = 0.05). In conclusion, the presence of ASP on LS represents confirmed or highly probable CA in only 1/3 of patients and is more likely to indicate true CA in older patients with increased LV wall thickness. Although a larger, prospective study is needed to confirm these findings, 1/3 should be considered as a large diagnostic yield that justifies further testing, given the poor outcomes associated with CA diagnosis.
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Affiliation(s)
- Eisha Wali
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Martin Gruca
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Cristiane Singulane
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Juan Cotella
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Brittney Guile
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Roydell Johnson
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, The University of Chicago Medical Center, Chicago, Illinois.
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Single Center Experience of Autologous Stem Cell Transplantation in Patients with Systemic Light Chain Amyloidosis in Korea. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:97-103. [PMID: 36464620 DOI: 10.1016/j.clml.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Systemic light chains is the most common systemic amyloidosis. In patients with AL amyloidosis, the prognosis is influenced by the extent of organ damage, especially cardiac involvement. Autologous stem cell transplantation (ASCT) is a highly effective treatment for AL amyloidosis for selective patient METHODS: One hundred patients treated with ASCT for AL amyloidosis were reviewed in the Samsung Medical Center amyloidosis cohort. The cardiac, renal, and hematologic response was analyzed, and survival results compared based on organ involvement and hematologic response. RESULTS The most common involved organ was kidney (n = 62) followed by heart (n = 50). The organ response rate was 44.0% and 37.1% in the patients with cardiac and renal involvement, respectively. In hematologic response, overall response rate (ORR) was 79.0%, including 48.0% complete response (CR). Median overall survival (OS) in patients with and without hematologic CR were not reached and 64.2 months (95% CI, 19.5 to 109.0), respectively (P < .001). The survival rate was not significantly different between patients with or without cardiac or renal involvement. Treatment-related mortality (TRM) in 30 days and 100 days was 2.0% and 3.0%, respectively. CONCLUSIONS ASCT is an effective treatment option for eligible patients with AL amyloidosis. Achieving hematologic CR is essential for long-term survival.
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Bomsztyk J, Khwaja J, Wechalekar AD. Recent guidelines for high dose chemotherapy and autologous stem cell transplant for systemic AL amyloidosis: a practitioner's perspective. Expert Rev Hematol 2022; 15:781-788. [PMID: 36039749 DOI: 10.1080/17474086.2022.2115353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION High dose melphalan followed by autologous stem cell transplant (ASCT) has been transformative in treating AL amyloidosis since the early nineties. Recently, the European Haematology Association (EHA) and International Society of Amyloidosis (ISA) have developed a combined guideline for the management of patients undergoing an ASCT for AL amyloidosis. AREAS COVERED In this practitioner's perspective, we review the guideline, focussing on 6 major areas and offer practical advice for its application. We provide a perspective on the optimal use of ASCT and its potential application in the future. EXPERT OPINION The EHA-ISA guideline comprehensively outlines the practicalities of performing an ASCT in AL amyloidosis. The critical aspect is careful patient selection. Vigilant fluid balance assessments are crucial as associated complications are common and dangerous.The role of ASCT is changing with improving haematological responses associated with novel agents. Evidence is limited for the use of ASCT in patients who achieve a complete haematological response (CR). Therefore, ASCT should be considered for those who only achieve a very good partial response (VGPR)/partial response (PR) and fulfil the strict selection criteria. Future research identifying the cohort who would benefit most from ASCT in the era of novel therapies is warranted.
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Affiliation(s)
- Joshua Bomsztyk
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, NW1 2BU, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London, Rowland Hill Street, London NW3 2PF, UK.,Department of Haematology, University College London Hospitals, London, NW1 2BU, UK
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7
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Gustine JN, Staron A, Szalat R, Mendelson L, Joshi T, Ruberg FL, Siddiqi O, Gopal DM, Edwards CV, Havasi A, Kaku M, Lau KHV, Berk JL, Sloan JM, Sanchorawala V. Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: a 25-year longitudinal study. Am J Hematol 2022; 97:1189-1199. [PMID: 35731907 DOI: 10.1002/ajh.26641] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/07/2022]
Abstract
High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I >0.1 ng/mL, and serum creatinine >2.0 mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p<0.001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joshua N Gustine
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Raphael Szalat
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Omar Siddiqi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Deepa M Gopal
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Camille V Edwards
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Michelle Kaku
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - K H Vincent Lau
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Pulmonology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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8
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Abdallah M, Sanchorawala V. Update on the Contemporary Treatment of Light Chain Amyloidosis Including Stem Cell Transplantation. Am J Med 2022; 135 Suppl 1:S30-S37. [PMID: 35081382 DOI: 10.1016/j.amjmed.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/14/2022] [Indexed: 11/24/2022]
Abstract
The management of immunoglobulin light chain (AL) amyloidosis is complex. Emerging data have shown promising results for several novel agents. We review the management of AL amyloidosis, including factors that determine transplant eligibility, treatment options for transplant-ineligible patients, and treatment options for relapsed/refractory AL amyloidosis. For carefully selected patients, high-dose melphalan and stem cell transplantation is recommended. Transplant eligibility criteria generally include biopsy-proven amyloidosis, evidence of a plasma cell dyscrasia, involvement of at least one major organ, and adequate performance status. For transplant-ineligible patients, bortezomib-based regimens are recommended, including: 1) bortezomib, oral melphalan, and dexamethasone (BMDex); 2) bortezomib, cyclophosphamide, and dexamethasone (CyBorD or VCd); and 3) subcutaneous daratumumab (DARA SC) and VCd. The latter option is based on a landmark trial that led to the first US Food and Drug Administration-approved therapy for AL amyloidosis. For relapsed/refractory disease, novel therapeutics including proteosome inhibitors, immunomodulatory agents, and monoclonal antibodies have shown promising results. In this review, we summarize data for various therapeutics in different clinical scenarios of AL amyloidosis.
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Affiliation(s)
- Maya Abdallah
- Section of Hematology/Oncology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Mass
| | - Vaishali Sanchorawala
- Section of Hematology/Oncology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Mass; Amyloidosis Center, Boston University School of Medicine, Boston, Mass.
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9
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Staron A, Zheng L, Doros G, Connors LH, Mendelson LM, Joshi T, Sanchorawala V. Marked progress in AL amyloidosis survival: a 40-year longitudinal natural history study. Blood Cancer J 2021; 11:139. [PMID: 34349108 PMCID: PMC8338947 DOI: 10.1038/s41408-021-00529-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/15/2022] Open
Abstract
The recent decades have ushered in considerable advancements in the diagnosis and treatment of systemic light chain (AL) amyloidosis. As disease outcomes improve, AL amyloidosis-unrelated factors may impact mortality. In this study, we evaluated survival trends and primary causes of death among 2337 individuals with AL amyloidosis referred to the Boston University Amyloidosis Center. Outcomes were analyzed according to date of diagnosis: 1980-1989 (era 1), 1990-1999 (era 2), 2000-2009 (era 3), and 2010-2019 (era 4). Overall survival increased steadily with median values of 1.4, 2.6, 3.3, and 4.6 years for eras 1–4, respectively (P < 0.001). Six-month mortality decreased over time from 23% to 13%. Wide gaps in survival persisted amid patient subgroups; those with age at diagnosis ≥70 years had marginal improvements over time. Most deaths were attributable to disease-related factors, with cardiac failure (32%) and sudden unexpected death (23%) being the leading causes. AL amyloidosis-unrelated mortality increased across eras (from 3% to 16% of deaths) and with longer-term survival (29% of deaths occurring >10 years after diagnosis). Under changing standards of care, survival improved and early mortality declined over the last 40 years. These findings support a more optimistic outlook for patients with AL amyloidosis.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Luke Zheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa M Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. .,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
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10
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Obici L, Adams D. Acquired and inherited amyloidosis: Knowledge driving patients' care. J Peripher Nerv Syst 2021; 25:85-101. [PMID: 32378274 DOI: 10.1111/jns.12381] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
Abstract
Until recently, systemic amyloidoses were regarded as ineluctably disabling and life-threatening diseases. However, this field has witnessed major advances in the last decade, with significant improvements in therapeutic options and in the availability of accurate and non-invasive diagnostic tools. Outstanding progress includes unprecedented hematological response rates provided by risk-adapted regimens in light chain (AL) amyloidosis and the approval of innovative pharmacological agents for both hereditary and wild-type transthyretin amyloidosis (ATTR). Moreover, the incidence of secondary (AA) amyloidosis has continuously reduced, reflecting advances in therapeutics and overall management of several chronic inflammatory diseases. The identification and validation of novel therapeutic targets has grounded on a better knowledge of key molecular events underlying protein misfolding and aggregation and on the increasing availability of diagnostic, prognostic and predictive markers of organ damage and response to treatment. In this review, we focus on these recent advancements and discuss how they are translating into improved outcomes. Neurological involvement dominates the clinical picture in transthyretin and gelsolin inherited amyloidosis and has a significant impact on disease course and management in all patients. Neurologists, therefore, play a major role in improving patients' journey to diagnosis and in providing early access to treatment in order to prevent significant disability and extend survival.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - David Adams
- National Reference Center for Familial Amyloid Polyneuropathy and Other Rare Neuropathies, APHP, Université Paris Saclay, INSERM U1195, Le Kremlin Bicêtre, France
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11
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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12
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Gudkova AY, Lapekin SV, Bezhanishvili TG, Trukshina MA, Davydova VG, Krutikov AN, Kulikov AN, Streltsova AA, Andreeva SE, Grozov RV, Poliakova AA, Kostareva AA, Salogub GN, Shlyakhto EV. AL-amyloidosis with cardiac involvement. Diagnostic capabilities of non-invasive methods. TERAPEVT ARKH 2021; 93:487-496. [DOI: 10.26442/00403660.2021.04.200689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 01/15/2023]
Abstract
There are presented the literature data and a description of the clinical course of the disease in isolated/predominant cardiac amyloidosis. Amyloid cardiomyopathy is the most common phenocopy of hypertrophic cardiomyopathy. The modern possibilities of non-invasive diagnostics using osteoscintigraphy for the differential diagnosis between amyloid cardiomyopathy caused by AL- and transthyretin amyloidosis are described in detail.
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13
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Second Stem Cell Transplantation for Relapsed Refractory Light Chain (AL) Amyloidosis. Transplant Cell Ther 2021; 27:589.e1-589.e6. [PMID: 33839316 DOI: 10.1016/j.jtct.2021.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/17/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) is an effective treatment modality in light chain (AL) amyloidosis but can be offered only to a subset of patients. The feasibility, benefit, and risks of second ASCT (ASCT2) have been rarely reported. The objective of this study was to assess the utility of ASCT2 in AL amyloidosis and to identify the target population with the greatest benefit. This retrospective study examined all AL patients who underwent ASCT2 for relapsed refractory disease between 2003 and 2020. Twenty-six patients were included. The use of ASCT2 has increased over time, from 2.5% of all ASCTs from 2003 to 2011 to 5% from 2012 to 2020 (P = .056). The median time between the first ASCT (ASCT1) and ASCT2 was 7.2 years (range, 0.6 to 17.7). Fifty-four percent of patients received at least one line of therapy between ASCTs. Second stem cell mobilization prior to ASCT2 was required in 42% of patients. Full-dose melphalan (200 mg/m2) was given to 73% of patients. Two patients had failed to engraft by day 100 but eventually recovered to normal blood counts. Both had second stem cell mobilization prior to ASCT2 with prior melphalan exposure. Four patients (15%) died before day 100. Progression-free and overall survival were significantly longer from ASCT2 for those who had durable remission after ASCT1 (≥5 years) and for those who did not receive therapy between ASCTs. ASCT2 is feasible and can produce favorable outcomes, especially among those with durable response to ASCT1. ASCT2, if chosen, should preferably be performed after durable response to ASCT1 and at first progression.
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14
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Nuvolone M, Basset M, Palladini G. A safety review of drug treatments for patients with systemic immunoglobulin light chain (AL) amyloidosis. Expert Opin Drug Saf 2021; 20:411-426. [PMID: 33583294 DOI: 10.1080/14740338.2021.1890023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In AL amyloidosis, a usually small plasma cell clone secretes unstable, amyloid-forming light chains, causing cytotoxicity and progressive (multi)organ function deterioration. Treatment aims at reducing/eradicating the underlying clone, to reduce/zero the supply of the amyloidogenic protein and halt the amyloidogenic cascade. AREAS COVERED Safety data of alkylating agents, proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies from clinical trials are reviewed. EXPERT OPINION Drugs used to treat AL amyloidosis are derived from experience with multiple myeloma or other B cell malignancies. However, treating AL amyloidosis is particularly challenging, as it implies delivering anti-neoplastic therapy to a hematologic malignancy directly causing (multi)organ function deterioration, often in elderly subjects with other comorbidities and polypharmacotherapy. This unique combination translates in increased patients' frailty and higher sensitivity toward treatment-related toxicities. Therefore, dose/schedule adjustments and special precautions are needed when translating treatment experience from multiple myeloma or other B cell malignancies to AL amyloidosis. Treatment of patients with AL amyloidosis should be risk adapted, tailored to individual patients' risk profile, considering the type and extent of organ involvement, and eventual comorbidity. As several classes of effective anti-plasma cell or B cell drugs are available, therapeutic choices are also influenced by individual drug's safety profile.
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Affiliation(s)
- Mario Nuvolone
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marco Basset
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amylodosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
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15
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Sharpley FA, Manwani R, Petrie A, Mahmood S, Sachchithanantham S, Lachmann HJ, Martinez De Azcona Naharro A, Gillmore JD, Whelan CJ, Fontana M, Cohen O, Hawkins PN, Wechalekar AD. Autologous stem cell transplantation vs bortezomib based chemotheraphy for the first-line treatment of systemic light chain amyloidosis in the UK. Eur J Haematol 2021; 106:537-545. [PMID: 33460466 DOI: 10.1111/ejh.13582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/13/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The benefit of autologous stem cell transplantation (ASCT) in the treatment of light chain (AL) amyloidosis requires re-evaluation in the modern era. This retrospective case-matched study compares ASCT to bortezomib for the treatment of patients with AL amyloidosis. METHODS Newly diagnosed patients with AL amyloidosis treated with ASCT or bortezomib between 2001 and 2018 were identified. Patients were excluded if the time from diagnosis to treatment exceeded 12 months. Patients were matched on a 1:1 basis, using a propensity-matched scoring approach. RESULTS A total of 136 propensity score-matched patients were included (ASCT n = 68, bortezomib n = 68). There was no significant difference in overall survival at two years (P = .908, HR: 0.95, CI: 0.41-2.20). For ASCT vs bortezomib: overall haematological response rate at 6 months was 90.6% vs 92.5%; organ response at 12 months: cardiac (70.0% vs 54%, P > .999), renal (74% vs 24%, P = .463) liver (21% vs 22%, P = .048); median progression-free survival (50 vs 42 months P = .058, HR: 0.61, CI: 0.37-1.02) and time to next treatment (68 vs 45 months, P = .145, HR: 0.61, CI: 0.31-1.19). More patients required treatment in the bortezomib group compared to ASCT group at 24 months (41 vs 23, Chi-squared P = .004) and 48 months (57 vs 41, Chi-squared P = .004). CONCLUSIONS This small retrospective study suggests that there is no clear survival advantage of ASCT over bortezomib therapy. A prospective randomised controlled trial evaluating ASCT in AL amyloidosis is critically needed.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Richa Manwani
- National Amyloidosis Centre, University College London, London, UK
| | - Aviva Petrie
- Biostatistics Unit, UCL Eastman Dental Institute, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK
| | | | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | | | | | - Carol J Whelan
- National Amyloidosis Centre, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
| | - Oliver Cohen
- National Amyloidosis Centre, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
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16
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17
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Gertz MA, Schonland S. Stem Cell Mobilization and Autologous Transplant for Immunoglobulin Light-Chain Amyloidosis. Hematol Oncol Clin North Am 2020; 34:1133-1144. [PMID: 33099429 DOI: 10.1016/j.hoc.2020.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Stem cell transplantation was one of the first proven effective regimens for the management of immunoglobulin light-chain amyloidosis. Criteria for patient selection and the mobilization regimen become important features in ensuring a safe outcome. The technique of stem cell transplantation has evolved considerably in parallel with the development of new chemotherapeutic agents for the management of amyloidosis. Optimal outcomes require both the use of effective novel agent induction and appropriate application of high-dose chemotherapy with subsequent stem cell reconstitution.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 Southwest First Street, W10, Rochester, MN 55905, USA.
| | - Stefan Schonland
- Department of Internal Medicine V, Division of Hematology/Oncology, Amyloidosis Center, Heidelberg University Hospital, Im Neuenheimer Feld 450, Heidelberg 69120, Germany
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18
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Szalat R, Sarosiek S, Havasi A, Brauneis D, Sloan JM, Sanchorawala V. Organ responses after highdose melphalan and stemcell transplantation in AL amyloidosis. Leukemia 2020; 35:916-919. [PMID: 32737434 DOI: 10.1038/s41375-020-1006-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 01/02/2023]
Affiliation(s)
- Raphael Szalat
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA.,Stem Cell Transplantation Program in the Section of Hematology and Oncology, Boston, MA, 02118, USA
| | - Shayna Sarosiek
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA.,Stem Cell Transplantation Program in the Section of Hematology and Oncology, Boston, MA, 02118, USA
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA.,Section of Renal Medicine, Boston Medical Center, Boston, MA, 02118, USA
| | - Dina Brauneis
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA.,Stem Cell Transplantation Program in the Section of Hematology and Oncology, Boston, MA, 02118, USA
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA.,Stem Cell Transplantation Program in the Section of Hematology and Oncology, Boston, MA, 02118, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine, Boston, MA, 02118, USA. .,Stem Cell Transplantation Program in the Section of Hematology and Oncology, Boston, MA, 02118, USA.
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19
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Systemic amyloidosis: moving into the spotlight. Leukemia 2020; 34:1215-1228. [PMID: 32269317 DOI: 10.1038/s41375-020-0802-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/13/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022]
Abstract
Systemic amyloidosis is a rare but increasingly recognised disease that is heterogeneous in presentation. Early diagnosis, whilst imperative, remains challenging but can improve prognosis and limit organ dysfunction. An increased repertoire of diagnostic imaging and histological techniques are becoming mainstream and promise to aid early diagnosis. Better risk stratification, via biomarkers and cytogenetics, has improved multidisciplinary treatment decisions. The use of novel agents has improved treatment efficacy, which translates into survival benefit. Newer strategies targeting pre-deposited amyloidogenic protein are under investigation. The current paper reviews available data relating to the most recent advances in the field of systemic amyloidosis.
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20
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Sanchorawala V. High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation in AL Amyloidosis. Acta Haematol 2020; 143:381-387. [PMID: 32248194 DOI: 10.1159/000506498] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/17/2022]
Abstract
AL amyloidosis is a systemic amyloidosis and is associated with an underlying plasma cell dyscrasia. High-dose intravenous melphalan and autologous stem cell transplantation was developed for the treatment of AL amyloidosis in the early 1990s and was prompted by its success in myeloma. This application has evolved significantly over the past three decades. This review provides a comprehensive assessment of eligibility criteria, stem cell collection, and mobilization strategies and regimens, risk-adapted melphalan dosing, role for induction and consolidation therapies as well as long-term outcome with respect to survival, hematologic response and relapse as well as organ responses following stem cell transplantation. Continued efforts to refine patient selection and management, and incorporate novel anti-plasma cell agents in combination or sequentially to further improve outcomes in AL amyloidosis are also discussed.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Stem Cell Transplantation Program of Section of Hematology and Oncology, Boston Medical Center, Boston, Massachusetts, USA,
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21
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Palladini G, Milani P, Merlini G. A powerful oral triplet for AL amyloidosis. Br J Haematol 2020; 189:605-606. [DOI: 10.1111/bjh.16471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo” Department of Molecular Medicine University of Pavia Pavia Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo” Department of Molecular Medicine University of Pavia Pavia Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo” Department of Molecular Medicine University of Pavia Pavia Italy
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