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Oganesyan A, Gregory A, Malard F, Ghahramanyan N, Mohty M, Kazandjian D, Mekinian A, Hakobyan Y. Monoclonal gammopathies of clinical significance (MGCS): In pursuit of optimal treatment. Front Immunol 2022; 13:1045002. [PMID: 36505449 PMCID: PMC9728929 DOI: 10.3389/fimmu.2022.1045002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of clinical significance (MGCS) represents a new clinical entity referring to a myriad of pathological conditions associated with the monoclonal gammopathy of undetermined significance (MGUS). The establishment of MGCS expands our current understanding of the pathophysiology of a range of diseases, in which the M protein is often found. Aside from the kidney, the three main organ systems most affected by monoclonal gammopathy include the peripheral nervous system, skin, and eye. The optimal management of these MGUS-related conditions is not known yet due to the paucity of clinical data, the rarity of some syndromes, and limited awareness among healthcare professionals. Currently, two main treatment approaches exist. The first one resembles the now-established therapeutic strategy for monoclonal gammopathy of renal significance (MGRS), in which chemotherapy with anti-myeloma agents is used to target clonal lesion that is thought to be the culprit of the complex clinical presentation. The second approach includes various systemic immunomodulatory or immunosuppressive options, including intravenous immunoglobulins, corticosteroids, or biological agents. Although some conditions of the MGCS spectrum can be effectively managed with therapies aiming at the etiology or pathogenesis of the disease, evidence regarding other pathologies is severely limited to individual patient data from case reports or series. Future research should pursue filling the gap in knowledge and finding the optimal treatment for this novel clinical category.
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Affiliation(s)
- Artem Oganesyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia,*Correspondence: Artem Oganesyan,
| | - Andrew Gregory
- Wayne State University School of Medicine, Detroit, MI, United States
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Nerses Ghahramanyan
- Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, INSERM, Saint-Antoine Research Centre, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Dickran Kazandjian
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, United States
| | - Arsène Mekinian
- Department of Internal Medicine (DMU i3), Sorbonne University, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France,French-Armenian Clinical Research Center, National Institute of Health, Yerevan, Armenia
| | - Yervand Hakobyan
- Department of Hematology and Transfusion Medicine, National Institute of Health, Yerevan, Armenia,Department Of Adult Hematology, Hematology Center after Prof. R. Yeolyan, Yerevan, Armenia
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Kim JG, Kim HR, You MH, Shin DH, Choi JS, Bae YK. Necrobiotic Xanthogranuloma Coexists with Diffuse Normolipidemic Plane Xanthoma and Multiple Myeloma. Ann Dermatol 2019; 32:53-56. [PMID: 33911709 PMCID: PMC7992639 DOI: 10.5021/ad.2020.32.1.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/10/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022] Open
Abstract
Necrobiotic xanthogranuloma (NXG), is a rare multisystem disease that manifests as cutaneous inflammatory lesions, and is commonly associated with lymphoproliferative disease. Diffuse normolipemic plane xanthoma (NX), is also a rare, acquired disease that is often associated with systemic diseases such as lymphoproliferative disease. Both of these diseases have been reported to be associated with monoclonal gammopathy (MG). However, there are few cases in which these diseases co-exist. A 78-year-old female, who had a known case of NX on the neck and axillary area, presented with an asymptomatic erythematous plaque on her left supraclavicular area. Histopathological examination showed lymphoid aggregates, necrobiotic areas, and granulomatous inflammation in the dermis. Numerous foreignbody and Touton type giant cells were noticed. Serum protein immunoelectrophoresis showed an IgG kappa type MG. Lipid profile of the patient was normal. Bone marrow examination showed plasma cell myeloma. Based on these histologic and laboratory results, we diagnosed this lesion as NXG coexisting with NX and multiple myeloma. She was started on treatment with bortezomib and melphalan for multiple myeloma, and high-dose systemic corticosteroid and triamcinolone intralesional injection for the skin lesion. After 3 months of treatment, the NXG skin lesion and MG improved.
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Affiliation(s)
- Joon Goon Kim
- Department of Dermatology, Yeungnam University College of Medicine, Daegu, Korea
| | - Hye Ri Kim
- Department of Dermatology, Yeungnam University College of Medicine, Daegu, Korea
| | - Moon Hyung You
- Department of Dermatology, Yeungnam University College of Medicine, Daegu, Korea
| | - Dong Hoon Shin
- Department of Dermatology, Yeungnam University College of Medicine, Daegu, Korea
| | - Jong Soo Choi
- Department of Dermatology, Yeungnam University College of Medicine, Daegu, Korea
| | - Young Kyung Bae
- Department of Pathology, Yeungnam University College of Medicine, Daegu, Korea
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Elkin VD, Sedova TG, Plotnikova EV, Kuznetsov ID, Novoselova MU. DIFFUSION NORMOLIPIDEMIC FLAT XANTHOMA, ASSOCIATED WITH HYPOCHROMIC ANEMIA. DESCRIPTION OF THE CASES. VESTNIK DERMATOLOGII I VENEROLOGII 2017. [DOI: 10.25208/0042-4609-2017-93-4-62-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The diffuse plane xanthoma (DPX) belongs to the class II of histiocytosis arising from the dermal dendritic cells (Histiocyte Society). The dominate role in the formation of the disease in the skin plays an accumulation of phagocytic immune complexes of macrophages. The clinical picture of the DPX is very specific and characterized by the appearance of periorbital xanthelasma and planar xanthomas on the skin of the trunk and extremities. The disease is often associated with hematological and lymphoproliferative diseases. The diagnosis is confirmed by histological examination.
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Lynch MC, Wood L, Anderson BE, Clarke LE. JAAD Grand Rounds. Asymptomatic dermal plaques. J Am Acad Dermatol 2015; 72:922-4. [PMID: 25890466 DOI: 10.1016/j.jaad.2012.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 05/21/2012] [Indexed: 11/26/2022]
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Szalat R, Pirault J, Fermand JP, Carrié A, Saint-Charles F, Olivier M, Robillard P, Frisdal E, Villard EF, Cathébras P, Bruckert E, Chapman MJ, Giral P, Guerin M, Lesnik P, Le Goff W. Physiopathology of necrobiotic xanthogranuloma with monoclonal gammopathy. J Intern Med 2014; 276:269-84. [PMID: 24428816 PMCID: PMC4279948 DOI: 10.1111/joim.12195] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
RATIONALE Xanthomatosis associated with monoclonal gammopathy includes hyperlipidaemic xanthoma (HX), normolipidaemic xanthoma (NX) and necrobiotic xanthogranuloma (NXG). All three pathologies are characterized by skin or visceral lesions related to cholesterol accumulation, monoclonal immunoglobulin (MIg) and hypocomplementemia. The pathophysiology underlying NXG remains unknown although the involvement of MIg is suspected. OBJECTIVE To provide further insights into the pathophysiology of NXG, we evaluated the plasma lipid phenotype, mechanisms involved in cellular cholesterol accumulation and role of MIg in an analysis of blood and plasma markers of inflammation in 16 patients with xanthomatosis [NXG (n = 8) and NX (n = 8)] associated with monoclonal IgG relative to the relevant controls. RESULTS The lipid profile of patients with NXG was characterized by a low HDL-C phenotype and an abnormal distribution of HDL particles. Sera from patients with NXG induced cholesterol accumulation in human macrophages. This accumulation was due in part to a significant reduction in the HDL capacity to promote cholesterol efflux from macrophages, which was not found in the case of NX. The MIg of NXG and NX patients was tested positively by ELISA to recognize a large spectrum of lipoproteins. High plasma levels of pro-inflammatory cytokines (TNFα and IL-6), soluble cytokine receptors (sIL-6R, sTNFRI and sTNFRII), adhesion molecules (VCAM-1 and ICAM-1) and chemokines (MCP-1, IL-8 and MIP-1α) were observed in both patients with NXG and NX, revealing a specific xanthoma inflammatory signature which was inversely correlated with plasma levels of anti-inflammatory HDL. However, patients with NXG were distinguished by elevated levels of IL-15 and a marked increase in the rate of intermediate CD14++CD16+ monocytes. CONCLUSION This study revealed that NXG is characterized by impaired macrophage lipid homeostasis associated with a systemic inflammatory profile that may result from the interaction of MIg and lipoproteins.
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Affiliation(s)
- R Szalat
- Département d'immunologie Clinique, Hôpital Saint Louis, Paris, France; EA3963, Université Paris 7 Denis Diderot, INSERM, IFR105, Institut Universitaire d'Hématologie, Paris, France
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Simão dos Santos B, Diniz A, Estrella R, Rochael M. Xanthomatous lesions: atypical presentation of primary systemic amyloidosis. Int J Dermatol 2013; 52:1403-5. [PMID: 24164157 DOI: 10.1111/j.1365-4632.2011.05156.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bruno Simão dos Santos
- Dermatology2Pathology, Hospital Universitário Antonio Pedro - UFF Rua Marques de Paraná 303 - Centro, Niterói Rio de Janeiro 24033-900 Brazil
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Abstract
Xanthomas are a common manifestation of lipid metabolism disorders. They include hyperlipemic xanthoma, normolipemic xanthoma, and a related condition, necrobiotic xanthogranuloma (NXG). All 3 forms can be associated with monoclonal immunoglobulin (MIg). In an attempt to improve diagnosis, understanding, and treatment of this association, we retrospectively analyzed a personal series of 24 patients (2 hyperlipemic xanthoma, 11 normolipemic xanthoma, and 11 NXG) and 230 well-documented reports from the literature. With the exception of the nodules and plaques featured in NXG, the clinical presentation of xanthomatous lesions usually resembled that seen in common hyperlipidemic forms and could not be used to suspect MIg-associated xanthomas. Extracutaneous sites were not rare. The MIg was an IgG in 80% of cases. Myeloma was diagnosed in 35%. Hypocomplementemia with low C4 fraction was present in 80% of studied patients. Low C1 inhibitor serum levels were found in 53%. Cryoglobulinemia was detected in 27%. These abnormalities suggest immune complex formation because of interactions between the MIg and lipoproteins and argue in favor of a causal link between MIg and xanthomas. Monoclonal gammopathy therapy could thus be an option. Indeed, among the patients who received chemotherapy, hematologic remission was accompanied by improvement in xanthoma lesions in several cases.
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Cham E, Siegel D, Ruben BS. Cutaneous xanthogranulomas, hepatosplenomegaly, anemia, and thrombocytopenia as presenting signs of juvenile myelomonocytic leukemia. Am J Clin Dermatol 2010; 11:67-71. [PMID: 20000879 DOI: 10.2165/11311130-000000000-00000] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The development of xanthogranulomas has been linked to hematologic malignancies in children and adults, based on a number of reports in the literature. In children, a specific association between juvenile xanthogranuloma, neurofibromatosis 1, and juvenile myelomonocytic leukemia has been described. We report a case of a 9-month-old child, without a known diagnosis of neurofibromatosis 1, who presented with hepatosplenomegaly, anemia, thrombocytopenia, and multiple cutaneous nodules, which were confirmed to be juvenile xanthogranulomas upon biopsy. A concurrent work-up showed that the child had juvenile myelomonocytic leukemia. Although cutaneous juvenile xanthogranulomas are benign lesions, in several reported cases they have been shown to herald leukemia. This association between xanthogranulomas and hematologic malignancy is poorly understood. Juvenile xanthogranulomas have a number of morphologic variants and clinical presentations that can be confused with the cutaneous lesions of Langerhans cell histiocytosis and dermatofibroma. Recognition of the broad clinicopathologic spectrum of juvenile xanthogranulomas is critical for proper diagnosis.
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Affiliation(s)
- Elaine Cham
- Department of Pathology, Evanston Northwestern Healthcare, Evanston, Illinois, USA
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Koçak M, Keleş H, Yakaryilmaz F, Bozdoğan O, Güliter S. Diffuse plane xanthomatosis in a patient with Budd-Chiari syndrome and monoclonal gammopathy. Indian J Dermatol 2010; 54:369-71. [PMID: 20101341 PMCID: PMC2807716 DOI: 10.4103/0019-5154.57616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Diffuse plane xanthomas are characterized by the presence of yellowish plaques on the eyelids, neck, upper trunk, buttocks, and flexural folds. Histology shows foamy histiocytes in the dermis. Approximately half of the cases are associated with lymphoproliferative disorders. Budd-Chiari syndrome is an uncommon condition induced by thrombotic or nonthrombotic obstruction of hepatic venous outflow. We present a case of diffuse plane xanthoma in a 62-year-old man who developed normolipemic plane xanthomas coinciding with Budd-Chiari syndrome and monoclonal gammopathy. We review the English-language literature regarding the rare association of xanthomas and Budd-Chiari syndrome.
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Affiliation(s)
- Mukadder Koçak
- Department of Dermatology, University of Kirikkale, School of Medicine, Ankara, Turkey.
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Campanati A, Goteri G, Simonetti O, Marconi B, Brandozzi G, Ganzetti G, Giuliodori K, Offidani A. Normolipemic plane xanthomatosis with acute development preceding the clinical onset of rheumatoid arthritis. J Cutan Pathol 2009; 36 Suppl 1:13-5. [PMID: 19508500 DOI: 10.1111/j.1600-0560.2009.01191.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rongioletti F, Patterson JW, Rebora A. The histological and pathogenetic spectrum of cutaneous disease in monoclonal gammopathies. J Cutan Pathol 2008; 35:705-21. [DOI: 10.1111/j.1600-0560.2007.00884.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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