"PARANEOPLASTIC" SYNDROMES ASSOCIATED WITH MONOCLONAL LYMPHOCYTE AND PLASMA CELL PROLIFERATION

IgM myeloma and Waldenstrom's macroglobulinemia: a distinct clinical feature, histology, immunophenotype, and chromosomal abnormality

Multiple myeloma represents a malignant proliferation of plasma cells derived from a single clone within the bone marrow. While the cause of myeloma is not known, interleukin 6 may play a role in driving myeloma cell proliferation. Waldenstrom's macroglobulinemia (WM) is a proliferative disease of B-lymphocytes. The cells have lymphoplasmacytoid features and secrete IgM. It is important to distinguish between IgM myeloma and WM as they have distinct clinical courses and prognoses, and treatment strategies are therefore different. The clinical characteristics of a patient diagnosed with IgM myeloma, and his excellent response to treatment are reported here.

Pathogenesis and therapy of neuropathies associated with monoclonal gammopathies

Approximately 10% of patients with peripheral neuropathy of otherwise unknown etiology have an associated monoclonal gammopathy. Both the neuropathies and the monoclonal gammopathies in these patients are heterogeneous, but several distinct clinical syndromes that may respond to specific therapies can be recognized. It is important to recognize these syndromes because monoclonal gammopathies also occur in 1% of the normal adult population, and in some cases, monoclonal gammopathies are coincidental and unrelated to the neuropathy. In patients with IgM monoclonal gammopathies, IgM M proteins frequently have autoantibody activity and are implicated in the pathogenesis of the neuropathy. IgM M proteins that bind to myelin-associated glycoprotein (MAG) have been shown to cause demyelinating peripheral neuropathy; anti-GM1 antibody activity is associated with predominantly motor neuropathy, and anti-sulfatide or chondroitin sulfate antibodies are associated with sensory neuropathy. The IgM monoclonal gammopathies may be malignant or nonmalignant, and polyclonal antibodies with the same specificities are associated with similar clinical presentations in the absence of monoclonal gammopathy. IgG or IgA monoclonal gammopathies are associated with neuropathy in patients with osteosclerotic myeloma or the POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy myeloma, and skin changes). Amyloidosis or cryoglobulinemic neuropathies can occur with either IgM or IgG and IgA monoclonal gammopathies. Therapeutic intervention depends on the specific clinical syndrome but is generally directed at removing the autoantibodies, reducing the number of monoclonal B cells, and interfering with the effector mechanisms.

Increase in the suppressor-inducer T cell subset in multiple myeloma and monoclonal gammopathy of undetermined significance

The expression of CD4 (helper-inducer), CD8 (suppressor-cytotoxic) and CD4 subpopulations (2H4 and 4B4) were studied in patients with multiple myeloma, monoclonal gammopathy of undetermined significance (MGUS) and in healthy controls. The percentages of CD4+ cells and CD8+ cells among total T cells were not different between the three groups studied. However the percentage of CD4+ cells of the suppressor-inducer type (CD4 + 2H4 +) was 53 +/- 9% in patients with MGUS, and 51 +/- 9% in those with MM, compared to 46 +/- 5 in the controls (P = 0.033 and P = 0.07 respectively). A significant negative correlation between serum polyclonal IgM and the percentage of CD4 + 2H4 + cells was found in patients with MM but not in those with MGUS. No difference was found in the percentage of CD4 + 4B4 + (helper CD4+ cells) between the various groups. These findings suggest that the elevation of the suppressor-inducer subset occurs prior to clinical manifestations of MM, perhaps as an immune response to the malignant clone. The existence of elevated proportions of CD4 suppressor-inducer cells was associated with the hypogammaglobulinaemia observed in patients with MM. Since no hypogammaglobulinaemia was present in those with MGUS, additional factors are needed to explain the influence of the CD4 + 2H4 + cells on the production of immunoglobulins.

Altered cytokine activities are related to the suppression of synthesis of normal immunoglobulin in multiple myeloma

The content of peripheral blood B cells (B1+) was reduced in patients of multiple myeloma (MM) and not in those with benign monoclonal gammopathy (BMG) compared to normal donors (P less than 0.01). This observation correlated with the suppression of synthesis of normal immunoglobulin (Ig) in MM. Thus, cytokine activities regulating the proliferation of normal mature B cells, such as B cell stimulatory factor 1 (BSF-1)/interleukin 4 (IL-4), B cell growth inhibitory factor (BIF) and IL-2 in peripheral blood T cells, and IL-1 in peripheral blood adherent cells, were investigated in patients with BMG (n = 7) and MM (n = 28). All patients of MM having a marked suppression of synthesis of all other normal Ig, had significantly lower levels of BSF-1 activity and inversely higher levels of BIF activity than those of normal donors. However, patients with BMG having no suppression of synthesis of normal Ig had BSF-1 and BIF activities similar to normal donors. There was no significant difference in IL-1 and IL-2 activities between both normal donors and BMG versus MM patients. These data show that in MM altered cytokine activities correlate with suppression of synthesis of normal Ig.

T-cells of multiple myeloma patients triggered by the autologous mixed lymphocyte reaction suppress polyclonal immunoglobulin synthesis

To elucidate the possible role of T-cells of patients with multiple myeloma (MM) in the suppression of polyclonal immunoglobulin synthesis. T-cells with and without prior activation by the autologous mixed lymphocyte reaction (AMLR) were added to normal immunoglobulin (Ig)-secreting cultures. The suppression induced by AMLR-activated T-cells from patients with MM was compared to that induced by AMLR-activated T-cells from apparently normal controls. The addition of 10% unstimulated autologous T-cells from patients with MM resulted in minimal suppression of IgG synthesis (87 +/- 19% of baseline values for patients and 115 +/- 21% for controls, no significant difference). The suppression sharply increased when T-cells were preactivated by AMLR and then added in the same concentration to the IgG-secreting cultures (38 + 12% of baseline values for patients compared to 106 + 14% for controls, P less than 0.05). AMLR cultures were performed in the presence of adherent monocytes and after their depletion. The T-cell suppressor effect on normal IgG synthesis was unchanged after monocyte depletion. T-cells preactivated in the AMLR from patients with MM sharply suppress in vitro polyclonal IgG synthesis, and the activation of these suppressor T-cells is not dependent on the presence of monocytes.

Spectrum and frequency of autoimmune derangements in lymphoproliferative disorders: analysis of 637 cases and comparison with myeloproliferative diseases

The records of 637 patients with lymphoproliferative disorders and 346 patients with myeloproliferative disorders were retrospectively analysed for the presence of additional autoimmune derangements. The frequency of autoimmune perturbations in lymphoproliferative diseases (51 cases; 8.0%) was significantly higher than in myeloproliferative diseases (six cases; 1.7%; P less than 0.0001). Rheumatic disorders, autoallergic haematological manifestations and other organ-specific autoimmune derangements were responsible for about one third each of the observed disturbances. Autoimmune diseases which preceded the onset of malignancy, occurred in lymphoproliferative and myeloproliferative disorders with a comparable frequency without significant differences between individual subgroups of lymphoproliferative diseases. In contrast, autoimmune complications developing in the course of the neoplastic disease were significantly more frequent in lymphoproliferative (4.9%) than in myeloproliferative disorders (0.3%; P less than 0.0005). Here marked differences were observed between individual lymphoma entities, the rate of concomitant autoimmune derangements ranging from zero to over 15%. With the exception of centroblastic-centrocytic lymphoma which in no case was associated with secondary autoimmune complications, the proportion of patients with autoimmune perturbations increased with improving prognosis of the lymphoproliferative diseases. Possible pathogenetic mechanisms involved in the manifestation of autoimmune complications in malignant lymphomas are discussed.

Neuropathy and anti-myelin-associated glycoprotein IgM M proteins: T cell regulation of M protein secretion in vitro

In patients with plasma cell dyscrasia, individual clones of antibody-producing cells proliferate abnormally and secrete monoclonal antibodies or M proteins in excess. The cause of the monoclonal proliferation of lymphocytes and M protein secretion is unknown and it is not known whether the M protein-secreting B cells are autonomous or capable of responding to regulatory T cells. We carried out experiments using lymphocytes from a patient with neuropathy and plasma cell dyscrasia whose IgM M protein bound to the myelin-associated glycoprotein (MAG) to determine whether secretion of the M protein in vitro was responsive to T cell help or suppression. M protein secretion was measured by an enzyme-linked immunosorbent assay system for measuring anti-MAG IgM, and the number of M protein-secreting lymphocytes was enumerated by a reverse hemolytic plaque assay specific for the M protein idiotype. The patient's B cells were maximally stimulated by pokeweed mitogen-activated autologous OKT4+ T-helper cells and the helper effect was inhibited by OKT8+ suppressor/cytotoxic T cells. Low levels of M protein secretion in the absence of T cells were also observed and there was partial stimulation of M protein secretion by T cells in the absence of pokeweed mitogen.

Cholecystitis associated with myelomatosis

A case of myeloma presenting as acute cholecystitis unresponsive to conventional management is reported. The impairment of the immunological response is a well-known aspect of myeloma, although this usually takes the form of recurrent respiratory infections. It is unusual for acute on chronic cholecystitis, a predominantly Gram-negative infection, to present in this way.

Pancytopenia with hypercellular bone marrow--a possible paraneoplastic syndrome in carcinoma of the lung: a report of three cases

Three patients with idiopathic pancytopenia and hypercellular bone marrow who developed carcinoma of the lung within two years of diagnosis are reported. All three patients had macrocytic anemia associated with a megaloblastic marrow in the presence of normal serum vitamin B12 and folic acid levels. Neutropenia with monocytosis, elevated serum muramidase and LAP scores, and increased fetal hemoglobin levels were also found. In all cases Ham's tests were negative with a normal bone marrow karyotype. In all three patients, pancytopenia due to myelodysplasia, a probable preleukemic state, was diagnosed initially prior to the appearance of carcinoma of the lung. One of the patients showed improved leukocyte and platelet counts during chemotherapy, while the other two died before chemotherapy could be administered. In the light of the above findings we suggest that carcinoma of the lung may be the cause of a paraneoplastic syndrome with pancytopenia, particularly in patients with a hypercellular marrow with a normal karyotype.

Myeloproliferative and lymphoproliferative disorders in the same patient

A 67-year-old man developed a Philadelphia-negative myeloproliferative disorder which initially manifested as marked thrombocytosis, followed two years later by marked leucocytosis. He subsequently developed an IgG lambda plasma cell dyscrasia together with a monoclonal proliferation of circulating lymphocytes with IgM kappa surface immunoglobulin. The lymphoid neoplasm was associated with a rapidly progressive and fatal course.

The kinetics of immunoglobulin synthesis by pokeweed mitogen stimulated peripheral blood lymphocytes in multiple myeloma

As a means of investigating the immunoglobulin (Ig) deficiency in multiple myeloma, the effects of pokeweed mitogen (PWM) on morphologic transformation and concomitant immunoglobulin synthesis and secretion kinetics were studied in peripheral blood lymphocytes (PBL) of normals and patients with myeloma. Lymphocyte Ig production kinetics, both in the unstimulated state and after five days of culture with PWM, were evaluated by 3H-leucine incorporation. B-lymphocytes were found to be decreased by EC3 rosetting in the myeloma patients studied. In addition their lymphocytes had a mean of 30% transformation compared to 53% for normals (P less than 0.005). After five days of mitogen stimulation in culture, myeloma PBL failed to show the rise in intracellular Ig production seen in normal PBL under similar conditions. Thus, myeloma patients were found to have decreased numbers of EC3 rosetting B-cells, decreased morphologic transformation rate in response to mitogenic stimulation, and failure to increase intracellular Ig after mitogenic stimulation. Possible etiologic mechanisms for the decreased Ig production are discussed.

Humoral immunosuppressive substance in mice bearing plasmacytomas

The mechanism by which plasmacytomas (PC) depress the primary immune response to sheep red cells was investigated by determining the ability of normal spleen cells to produce antibody when enclosed in Millipore chambers and implanted in PC-bearing mice. Chamber-enclosed normal spleen cells implanted in PC-bearing mice responded poorly to the sheep red cells when compared to similar cells enclosed in chambers and implanted in normal mice or in mice with other lymphoid and nonlymphoid tumors. The data suggest that PC-induced immune suppression is mediated by a humoral factor.