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Lee HW, Kim SM, Park HD. Evaluating the HYDRASHIFT 2/4 Daratumumab assay: a powerful approach to assess treatment response in multiple myeloma. Clin Chem Lab Med 2024; 62:2223-2232. [PMID: 38630027 DOI: 10.1515/cclm-2024-0416] [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: 03/03/2024] [Accepted: 04/08/2024] [Indexed: 09/28/2024]
Abstract
OBJECTIVES This study evaluates the HYDRASHIFT assay's effectiveness in mitigating daratumumab interference on serum protein tests during multiple myeloma (MM) treatment, aiming to ensure an accurate assessment of treatment response. METHODS We analyzed 113 serum samples from 68 MM patients undergoing daratumumab treatment, employing both standard IF and the HYDRASHIFT assay. The assay's precision was determined through intra-day and inter-day variability assessments, while its specificity was verified using serum samples devoid of daratumumab. Comparative analysis of IF results, before and after the application of the HYDRASHIFT assay, facilitated the categorization of treatment responses in alignment with the International Myeloma Working Group's response criteria. RESULTS The precision underscored the assay's consistent repeatability and reproducibility, successfully eliminating interference of daratumumab-induced Gκ bands. Specificity assessments demonstrated the assay's capability to distinguish daratumumab from both isatuximab and naturally occurring M-proteins. Of the analyzed cases, 91 exhibited successful migration of daratumumab-induced Gκ bands, thereby enhancing the accuracy of treatment response classification. The remaining 22 cases did not show a visible migration complex, likely due to the low concentration of daratumumab in the serum. These findings underscore the assay's critical role in distinguishing daratumumab from endogenous M-protein, particularly in samples with a single Gκ band on standard IF, where daratumumab and endogenous M-protein had co-migrated. CONCLUSIONS The HYDRASHIFT assay demonstrates high precision, specificity, and utility in the accurate monitoring of treatment responses in MM patients receiving daratumumab. This assay represents a significant advancement in overcoming the diagnostic challenges posed by daratumumab interference.
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Affiliation(s)
- Hyun-Woo Lee
- Department of Laboratory Medicine and Genetics, 36626 Samsung Medical Center , Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Mi Kim
- Department of Laboratory Medicine and Genetics, 36626 Samsung Medical Center , Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyung-Doo Park
- Department of Laboratory Medicine and Genetics, 36626 Samsung Medical Center , Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Department of Medical Device Management and Research, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea
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Lin SY, Lu KJ, Zheng XN, Hou J, Liu TT. Efficacy and survival outcome of allogeneic stem-cell transplantation in multiple myeloma: meta-analysis in the recent 10 years. Front Oncol 2024; 14:1341631. [PMID: 39144827 PMCID: PMC11322114 DOI: 10.3389/fonc.2024.1341631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 07/09/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Allogeneic hematopoietic cell transplantation (alloHCT) possessed direct cytotoxicity and graft-versus-multiple myeloma effect (GvMM). Growing trials have shown survival benefits of performing alloHCT in both newly diagnosed and relapsed MM. Methods We aimed to provide a comprehensive analysis in the recent 10 years to verify the efficacy and survival outcome of alloHCT in MM patients. A total of 61 studies which provide data between 14/04/2013 and 14/04/2023 and a total of 15,294 data from MM patients who had undergone alloSCT were included in our study. The best response rates (CR, VGPR, PR) and survival outcomes (1-, 2-, 3-,5-, and 10-year OS, PFS, NRM) were assessed. We further conducted meta-analysis in the NDMM/frontline setting and RRMM/salvage setting independently. Results The pooled estimate CR, VGPR, and PR rates were 0.45, 0.21, and 0.24, respectively. The pooled estimates of 1-, 2-, 3-, 5-, and 10-year OS were 0.69, 0.57, 0.45, 0.45, and 0.36, respectively; the pooled estimates of 1-, 2-, 3-, 5-, and 10-year PFS were 0.47, 0.35, 0.24, 0.25, and 0.28, respectively; and the pooled estimates of 1-, 2-, 3-, 5-, and 10-year NRM were 0.16, 0.21, 0.16, 0.20, and 0.15, respectively. In the NDMM/upfront setting, the pooled estimate CR rate was 0.54, and those for 5-year OS, PFS, and NRM were 0.69, 0.40, and 0.11, respectively. In a relapsed setting, the pooled estimate CR rate was 0.31, and those for 5-year OS, PFS, and NRM were 0.24, 0.10, and 0.15, respectively. Discussion Our results showed constant OS, PFS, and NRM from the third year onwards till the 10th year, suggesting that alloSCT has sustained survival benefits. Good response rate and promising survival outcome were observed in the NDMM/ frontline setting. Conclusion Although comparing with other treatments, alloSCT had a lower response rate and poorer short-term survival outcome, long-term follow-up could reveal survival benefits of alloSCT in MM patients.
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Affiliation(s)
| | | | | | - Jian Hou
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Ting Ting Liu
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Oliver-Caldes A, Soler-Perromat JC, Lozano E, Moreno D, Bataller A, Mozas P, Garrote M, Setoain X, Aróstegui JI, Yagüe J, Tovar N, Jiménez R, Rodríguez-Lobato LG, Cibeira MT, Rosiñol L, Bladé J, Juan M, Fernández de Larrea C. Long-Term Responders After Autologous Stem Cell Transplantation in Multiple Myeloma. Front Oncol 2022; 12:936993. [PMID: 35865461 PMCID: PMC9294166 DOI: 10.3389/fonc.2022.936993] [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: 05/05/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionMultiple myeloma (MM) is considered an incurable hematological neoplasm. For transplant-eligible patients, initial treatment includes an induction phase followed by an autologous stem cell transplantation (ASCT). Despite the introduction of several drugs in the past years, relapses still occur. Nevertheless, some patients achieve sustained responses after successful induction treatment and ASCT.MethodsWe retrospectively evaluated all patients diagnosed with MM in our institution who underwent induction treatment and ASCT between 1990 and 2015. The subset of patients who achieved a sustained response (any degree) for 5 or more years after ASCT without further treatment or signs of progression were distinguished as “long-term responders” (LTRs). In the non-LTR group, a cohort referred to as “prolonged responders” (PLRs) showed sustained response of at least 5 years after ASCT but eventually relapsed. We collected and analyzed clinical and laboratory data.ResultsTwo hundred and fifty patients were diagnosed with MM and received induction treatment and ASCT at our institution in the study period. Among them, 54 (21.6%) patients met the criteria for LTR. Some diagnostic features such as a younger age, female gender, ECOG performance status of 0, lower International Staging System (ISS) stage, lower bone marrow plasma cell infiltration, and lower serum levels of calcium, C-reactive protein, and lactate dehydrogenase (LDH) were found to be more prevalent in LTR. Female gender, an ECOG performance status of 0, a localized Durie-Salmon stage, an ISS of I–II, the absence of bone disease, and an LDH within normal range were also predictive of longer progression-free survival (PFS) and overall survival (OS) in the whole cohort. The depth of the response achieved after induction and ASCT as well as the administration of an IMID-based maintenance regimen may play a role in the differences observed on PFS between cohorts. A detectable M-protein with a monoclonal gammopathy of undetermined significance (MGUS)-like behavior was detected in one-third of LTR after ASCT. Although relapses continue to occur in patients who achieve a 5-year treatment-free period after ASCT, a plateau is observed in the survival curves at approximately 21 years of follow-up.
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Affiliation(s)
- Aina Oliver-Caldes
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Juan Carlos Soler-Perromat
- Radiology Department Centre de Diagnòstic per la Imatge Clínic (CDIC), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ester Lozano
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Cell Biology, Physiology and Immunology, Faculty of Biology, Universitat de Barcelona (UB), and Institute of Biomedicine of the University of Barcelona (IBUB), Barcelona, Spain
| | - David Moreno
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alex Bataller
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pablo Mozas
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marta Garrote
- Hematopathology Unit, Pathology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Xavier Setoain
- Nuclear Medicine Department, Hospital Clinic de Barcelona, Biomedical Imaging Group, Biomedical Research Networking Center in Bioengineering, Biomaterials and Nanomedicine (CIBER-BBN), Barcelona, Spain
| | | | - Jordi Yagüe
- Immunology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Natalia Tovar
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Raquel Jiménez
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Luis Gerardo Rodríguez-Lobato
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - M. Teresa Cibeira
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Rosiñol
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Joan Bladé
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Manel Juan
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Immunology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Carlos Fernández de Larrea
- Hematology Department, Amyloidosis and Myeloma Unit, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- *Correspondence: Carlos Fernández de Larrea,
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Rituximab-Induced Remission in Epstein-Barr Virus-Associated Glomerulonephritis. Kidney Int Rep 2020; 5:2109-2113. [PMID: 33163732 PMCID: PMC7609913 DOI: 10.1016/j.ekir.2020.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/29/2020] [Accepted: 08/25/2020] [Indexed: 11/22/2022] Open
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Eisfeld C, Eßeling E, Wullenkord R, Khandanpour C, Reusch J, Mikesch JH, Reicherts C, Kerkhoff A, Schliemann C, Kessler T, Mesters RM, Berdel WE, Lenz G, Stelljes M. Long-term survival and polyclonal immunoglobulin reconstitution after allogeneic stem cell transplantation in multiple myeloma. Ann Hematol 2020; 99:1907-1915. [PMID: 32444892 PMCID: PMC7340674 DOI: 10.1007/s00277-020-04068-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/28/2020] [Indexed: 01/19/2023]
Abstract
Despite significant progress made in the treatment of patients with multiple myeloma (MM) in the last decade, for patients with early relapse or rapidly progressing high-risk disease, allogeneic hematopoietic stem cell transplantation (SCT) might be an option leading to long-term survival. Here, we retrospectively analyzed the outcomes of 90 MM patients who received allogeneic SCT in our center between 1999 and 2017. We specifically assessed the association of impaired humoral immune reconstitution, referred to as immunoparesis, and post-transplant survival. Sixty-four patients received allogeneic SCT in relapse following 2–7 lines of therapy; 26 patients received upfront tandem autologous-allogeneic SCT. With a median follow-up of 76 months, OS and PFS were 52.6% (95% CI 42.9–64.3) and 36.4% (95% CI 27.6–47.9) at 2 years and 38.6% (95% CI 29.2–51.1) and 25.3% (95% CI 17.5–36.4) at 5 years, respectively. Receiving more than two therapy lines prior to transplantation was an independent risk factor for OS (HR 3.68, 95% CI 2.02–6.70) and PFS (HR 3.69, 95% CI 2.09–6.50). In a landmark analysis at day 200, prolonged immunoparesis was associated with reduced OS (HR 3.22, 95% CI 1.14–9.11). Allogeneic stem cell transplantation offers an additional treatment element that may lead to long-term remission in selected patients with poor prognosis, probably exploiting graft-versus-myeloma effects. Immunoparesis could potentially serve as an indicator for impaired survival following allogeneic transplantation, an observation to be further studied prospectively.
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Affiliation(s)
- Christine Eisfeld
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Eva Eßeling
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Ramona Wullenkord
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Cyrus Khandanpour
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Julia Reusch
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | | | | | - Andrea Kerkhoff
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | | | - Torsten Kessler
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Rolf M Mesters
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Wolfgang E Berdel
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Georg Lenz
- Department of Medicine A, University Hospital Münster, Münster, Germany
| | - Matthias Stelljes
- Department of Medicine A, University Hospital Münster, Münster, Germany.
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6
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Ye R, Kundrapu S, Gerson SL, Driscoll JJ, Beck R, Ali N, Landgren O, VanHeeckeren W, Luo G, Kroger N, Caimi P, De Lima M, Malek E. Immune Signatures Associated With Clonal Isotype Switch After Autologous Stem Cell Transplantation for Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2019; 19:e213-e220. [PMID: 30878316 PMCID: PMC7444684 DOI: 10.1016/j.clml.2018.12.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/19/2018] [Accepted: 12/28/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND High-dose chemotherapy and autologous stem cell transplantation (ASCT) are integral components of the overall treatment for patients with multiple myeloma (MM) aged ≤ 65 years. The emergence of oligoclonal immunoglobulin bands (ie, immunoglobulins differing from those originally identified at diagnosis [termed clonal isotype switch (CIS)]) has been reported in patients with MM after high-dose chemotherapy followed by autologous stem cell transplantation. However, the clinical relevance and the correlation with immune reconstitution remains unclear. PATIENTS AND METHODS Patients with MM who had undergone ASCT from 2007 to 2016 were included in the present study. The percentage of natural killer cells, B-cells, and T-cells was measured using flow cytometry in pre- and post-ASCT bone marrow samples. CIS was defined as the appearance of a new serum monoclonal spike on serum protein electrophoresis and immunofixation that differed from original heavy or light chain detected at diagnosis. RESULTS A retrospective analysis of 177 patients with MM who had undergone ASCT detected CIS in 39 (22%). CIS after ASCT correlated with improved progression-free survival (52.2 vs. 36.6 months; P = .21) and overall survival (75.1 vs. 65.4 months; P = .021). Patients with a relapse had an isotype that differed from a CIS, confirming the benign nature of this phenomenon. CIS was also associated with lower CD8 T-cell percentages and a greater CD4/CD8 ratio (2.8 vs. 0.2; P = .001) compared with patients who did not demonstrate a CIS, suggestive of more profound T-cell immune reconstitution in this group. CONCLUSION Taken together, our data have demonstrated that a CIS is a benign phenomenon and correlates with a reduced disease burden and enriched immune repertoire beyond the B-cell compartment.
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Affiliation(s)
- Rebecca Ye
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Sirisha Kundrapu
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Stanton L Gerson
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH
| | - James J Driscoll
- Division of Hematology and Oncology, The Vontz Center for Molecular Studies, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Rose Beck
- Department of Pathology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Naveed Ali
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Willem VanHeeckeren
- Division of Hematology and Oncology, University Hospital Cleveland Medical Center, Cleveland, OH
| | - George Luo
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Nicolaus Kroger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paolo Caimi
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Marcos De Lima
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ehsan Malek
- Adult Hematologic Malignancies and Stem Cell Transplant Program, Seidman Cancer Center, University Hospitals Cleveland Medical Center, Cleveland, OH; Case Western Reserve University School of Medicine, Cleveland, OH.
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Tate JR, Smith JD, Wijeratne N, Mollee P. Proposed Addendum to 2012 Recommendations for Standardised Reporting of Protein Electrophoresis in Australia and New Zealand. Clin Biochem Rev 2019; 40:23-30. [PMID: 30828117 PMCID: PMC6370285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
It is apparent that there is a need for greater harmonisation of the reporting and quantification of paraproteins on protein electrophoresis with the introduction of the electronic health record and recent survey findings indicating ongoing areas of heterogeneity on serum protein electrophoresis. The proposed addendum aims to update the 2012 recommendations for standardised reporting of protein electrophoresis in Australia and New Zealand. The sections which need to be updated include those on the quantification of gamma- and non-gamma-migrating paraproteins; interpretive commenting in specimens with a paraprotein and/or small abnormal bands; the utility of serum free light chains compared with Bence Jones protein measurement; and a new table with interpretive commenting for serum free light chains. It is expected that such standardised reporting will reduce both variation between laboratories and the risk of misinterpretation of results.
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Affiliation(s)
- Jillian R Tate
- Chemical Pathology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Qld 4029, Australia
| | - Joel D Smith
- Dorevitch Pathology, Heidelberg, Vic. 3084, Australia
| | - Nilika Wijeratne
- Dorevitch Pathology, Heidelberg, Vic. 3084, Australia
- Monash Pathology, Monash Health, Clayton, Vic. 3169, Australia
- Department of Medicine, Monash University, Clayton, Vic. 3169, Australia
| | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital, Brisbane, Qld 4102, Australia
- School of Medicine, University of Queensland, Brisbane, Qld 4102, Australia
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Iovino L, Mazziotta F, Buda G, Orciuolo E, Caracciolo F, Pelosini M, Morganti R, Galimberti S, Benedetti E, Petrini M. The Onset of Monoclonal and Oligoclonal Gammopathies Is a Good Prognostic Factor after Allogeneic Stem Cell Transplantation. Acta Haematol 2018; 141:7-11. [PMID: 30439709 DOI: 10.1159/000493416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/29/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Lorenzo Iovino
- Hematology Division, Pisa University Hospital, Pisa, Italy,
- Dudakov Lab, Program in Immunology, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA,
| | | | - Gabriele Buda
- Hematology Division, Pisa University Hospital, Pisa, Italy
| | | | | | | | - Riccardo Morganti
- Biostatistical Consulting, Pisa University Hospital, University of Pisa, Pisa, Italy
| | | | | | - Mario Petrini
- Hematology Division, Pisa University Hospital, Pisa, Italy
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Go RS, Rajkumar SV. How I manage monoclonal gammopathy of undetermined significance. Blood 2018; 131:163-173. [PMID: 29183887 PMCID: PMC5757684 DOI: 10.1182/blood-2017-09-807560] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/19/2017] [Indexed: 12/16/2022] Open
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is, in many ways, a unique hematologic entity. Unlike most hematologic conditions in which the diagnosis is intentional and credited to hematologists, the discovery of MGUS is most often incidental and made by nonhematologists. MGUS is considered an obligate precursor to several lymphoplasmacytic malignancies, including immunoglobulin light-chain amyloidosis, multiple myeloma, and Waldenström macroglobulinemia. Therefore, long-term follow-up is generally recommended. Despite its high prevalence, there is surprisingly limited evidence to inform best clinical practice both at the time of diagnosis and during follow-up. We present 7 vignettes to illustrate common clinical management questions that arise during the course of MGUS. Where evidence is present, we provide a concise summary of the literature and clear recommendations on management. Where evidence is lacking, we describe how we practice and provide a rationale for our approach. We also discuss the potential harms associated with MGUS diagnosis, a topic that is rarely, if ever, broached between patients and providers, or even considered in academic debate.
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Affiliation(s)
- Ronald S Go
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - S Vincent Rajkumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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Tate JR, Keren DF, Mollee P. A global call to arms for clinical laboratories – Harmonised quantification and reporting of monoclonal proteins. Clin Biochem 2018; 51:4-9. [DOI: 10.1016/j.clinbiochem.2017.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/05/2017] [Accepted: 11/13/2017] [Indexed: 12/11/2022]
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11
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van de Donk NWCJ, Otten HG, El Haddad O, Axel A, Sasser AK, Croockewit S, Jacobs JFM. Interference of daratumumab in monitoring multiple myeloma patients using serum immunofixation electrophoresis can be abrogated using the daratumumab IFE reflex assay (DIRA). Clin Chem Lab Med 2017; 54:1105-9. [PMID: 26812873 DOI: 10.1515/cclm-2015-0888] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/03/2015] [Indexed: 11/15/2022]
Abstract
Daratumumab is a fully human anti-CD38 IgG1-κ monoclonal antibody (mAb) currently being evaluated in several Phase 2 and 3 clinical studies for the treatment of multiple myeloma (MM). In this clinical case study we demonstrate that daratumumab can be detected as an individual monoclonal band in serum immunofixation electrophoresis (IFE). M-protein follow-up by IFE is part of the International Myeloma Working Group (IMWG) criteria to assess treatment response. Therefore, it is crucial that the daratumumab band is not confused with the endogenous M-protein of the patient during IFE interpretation. Moreover, a significant number of IgG-κ M-proteins co-migrate with daratumumab. Co-migration introduces a bias in the M-protein quantification since pharmacokinetic studies show that daratumumab peak plasma concentrations reach up to 1 g/L. More importantly, co-migration can mask clearance of the M-protein by IFE which is necessary for classification of complete response by IMWG criteria (negative serum IFE). For optimal M-protein monitoring the laboratory specialist needs to be informed when patients receive daratumumab, and it is essential that the laboratory specialist is aware that a slow migrating band in the γ-region in those patients may be derived from the daratumumab. A daratumumab specific IFE reflex assay (DIRA) has been developed and can be utilized to abrogate interference. The here described mAb interference is not limited to daratumumab, and as therapeutic antibodies gain approval and enter into common clinical practice, laboratory specialists will need additional processes to characterize IFE interference and distinguish endogenous M-protein from therapeutic antibodies.
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Ramirez-Alvarado M, Barnidge DR, Murray DL, Dispenzieri A, Marin-Argany M, Dick CJ, Cooper SA, Nasr SH, Ward CJ, Dasari S, Jiménez-Zepeda VH, Leung N. Assessment of renal response with urinary exosomes in patients with AL amyloidosis: A proof of concept. Am J Hematol 2017; 92:536-541. [PMID: 28295502 DOI: 10.1002/ajh.24717] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 02/01/2023]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a fatal complication of B-cell proliferation secondary to deposition of amyloid fibrils in various organs. Urinary exosomes (UEX) are the smallest of the microvesicles excreted in the urine. Previously, we found UEX of patients with AL amyloidosis contained immunoglobulin light chain (LC) oligomers that patients with multiple myeloma did not have. To further explore the role of the LC oligomers, UEX was isolated from an AL amyloidosis patient with progressive renal disease despite achieving a complete response. LC oligomers were identified. Mass spectrometry (MS) of the UEX and serum identified two monoclonal lambda LCs. Proteomics of the trypsin digested amyloid fragments in the kidney by laser microdissection and MS analysis identified a λ6 LC. The cDNA from plasma cell clone was from the IGLV- 6-57 family and it matched the amino acid sequences of the amyloid peptides. The predicted mass of the peptide product of the cDNA matched the mass of one of the two LCs identified in the UEX and serum. UEX combined with MS were able to identify 2 monoclonal lambda LCs that current clinical methods could not. It also identified the amyloidogenic LC which holds potential for response assessment in the future.
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Affiliation(s)
- Marina Ramirez-Alvarado
- Department of Biochemistry and Molecular Biology; Mayo Clinic; MN 55905 USA
- Department of Immunology; Mayo Clinic; MN 55905 USA
| | - David R. Barnidge
- Department of Laboratory Medicine and Pathology; Mayo Clinic; MN 55905 USA
| | - David L. Murray
- Department of Laboratory Medicine and Pathology; Mayo Clinic; MN 55905 USA
| | | | - Marta Marin-Argany
- Department of Biochemistry and Molecular Biology; Mayo Clinic; MN 55905 USA
| | | | - Shawna A. Cooper
- Department of Biochemistry and Molecular Biology; Mayo Clinic; MN 55905 USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology; Mayo Clinic; MN 55905 USA
| | | | - Surendra Dasari
- Health Sciences Research, Biomedical Statistics and Informatics; Mayo Clinic; MN 55905 USA
| | | | - Nelson Leung
- Division of Hematology; Mayo Clinic; MN 55905 USA
- Division of Nephrology and Hypertension; Mayo Clinic; MN 55905 USA
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A transplant “immunome” screening platform defines a targetable epitope fingerprint of multiple myeloma. Blood 2016; 127:3202-14. [DOI: 10.1182/blood-2015-10-676536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 03/22/2016] [Indexed: 12/13/2022] Open
Abstract
Key Points
The myeloma transplant B-cell immunome is predictive for response to treatment. It may be exploited by immunosequencing and library technology as a source for unique target structures and antibodies for immunotherapy.
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14
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Henry R, Glegg D. Use of isoelectric focusing to discriminate transient oligoclonal bands from monoclonal protein in treated myeloma. Clin Chem Lab Med 2016; 54:985-9. [PMID: 26641967 DOI: 10.1515/cclm-2015-0642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/31/2015] [Indexed: 01/13/2023]
Abstract
A 62-year-old diabetic man with prostate cancer first presented to our clinical laboratory in 2003 with a normal serum protein electrophoresis and immunofixation. In March 2009 he was diagnosed with an IgG κ myeloma. He underwent treatment and went into remission with the original paraprotein band being undetectable. Over the following 5 years, he developed oligoclonal bands and then eventually relapsed. Serum protein electrophoresis and immunofixation were inconclusive, however, isoelectrofocusing identified the oligoclonal pattern then the return of the original band, indicating relapse. This case illustrates the usefulness of an isoelectric focusing method to correctly determine clonality of small abnormal protein bands. It also highlights the need for appropriate commenting on reported results so that they are not confusing for clinicians.
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Keren DF, Schroeder L. Challenges of measuring monoclonal proteins in serum. ACTA ACUST UNITED AC 2016; 54:947-61. [DOI: 10.1515/cclm-2015-0862] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/06/2016] [Indexed: 01/16/2023]
Abstract
AbstractThe measurement of monoclonal protein (M-protein) is vital for stratifying risk and following individuals with a variety of monoclonal gammopathies. Direct measurement of the M-protein spike by electrophoresis and immunochemical measurements of specific isotypes or free light chains pairs has provided useful information about the quantity of M-protein. Nonetheless, both traditional electrophoresis and immunochemical methods give poor quantification with M-proteins smaller than 10 g/L (1 g/dL) when in the presence of polyclonal immunoglobulins that co-migrate with the M-protein. In addition, measurements by electrophoresis of M-proteins migrating in the β- and α-regions are contaminated by normal serum proteins in those regions. The most precise electrophoretic method to date for quantification involves exclusion of the polyclonal immunoglobulins by using the tangent skimming method on electropherograms, which provides a 10-fold improvement in precision. So far, however, tangent measurements are limited to γ migrating M-proteins. Another way to improve M-protein measurements is the use of capillary electrophoresis (CE). With CE, one can employ immunosubtraction to select a region of interest in the β region thereby excluding much of the normal proteins from the M-protein measurement. Recent development of an immunochemical method distinguishing heavy/light chain pairs (separately measuring IgGK and IgGL, IgAK and IgAL, and IgMK and IgML) provides measurements that could exclude polyclonal contaminants of the same heavy chain with the uninvolved light chain type. Yet, even heavy/light results contain an immeasurable quantity of polyclonal heavy/light chains of the involved isotype. Finally, use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) looms on the horizon as a means to provide more consistent and sensitive measurements of M-proteins.
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Clinical efficacy and management of monoclonal antibodies targeting CD38 and SLAMF7 in multiple myeloma. Blood 2015; 127:681-95. [PMID: 26631114 DOI: 10.1182/blood-2015-10-646810] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/26/2015] [Indexed: 01/19/2023] Open
Abstract
Immunotherapeutic strategies are emerging as promising therapeutic approaches in multiple myeloma (MM), with several monoclonal antibodies in advanced stages of clinical development. Of these agents, CD38-targeting antibodies have marked single agent activity in extensively pretreated MM, and preliminary results from studies with relapsed/refractory patients have shown enhanced therapeutic efficacy when daratumumab and isatuximab are combined with other agents. Furthermore, although elotuzumab (anti-SLAMF7) has no single agent activity in advanced MM, randomized trials in relapsed/refractory MM have demonstrated significantly improved progression-free survival when elotuzumab is added to lenalidomide-dexamethasone or bortezomib-dexamethasone. Importantly, there has been no significant additive toxicity when these monoclonal antibodies are combined with other anti-MM agents, other than infusion-related reactions specific to the therapeutic antibody. Prevention and management of infusion reactions is important to avoid drug discontinuation, which may in turn lead to reduced efficacy of anti-MM therapy. Therapeutic antibodies interfere with several laboratory tests. First, interference of therapeutic antibodies with immunofixation and serum protein electrophoresis assays may lead to underestimation of complete response. Strategies to mitigate interference, based on shifting the therapeutic antibody band, are in development. Furthermore, daratumumab, and probably also other CD38-targeting antibodies, interfere with blood compatibility testing and thereby complicate the safe release of blood products. Neutralization of the therapeutic CD38 antibody or CD38 denaturation on reagent red blood cells mitigates daratumumab interference with transfusion laboratory serologic tests. Finally, therapeutic antibodies may complicate flow cytometric evaluation of normal and neoplastic plasma cells, since the therapeutic antibody can affect the availability of the epitope for binding of commercially available diagnostic antibodies.
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