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Zanwar S, Le-Rademacher J, Durot E, D’Sa S, Abeykoon JP, Mondello P, Kumar S, Sarosiek S, Paludo J, Chhabra S, Cook JM, Parrondo R, Dispenzieri A, Gonsalves WI, Muchtar E, Ailawadhi S, Kyle RA, Rajkumar SV, Delmer A, Fonseca R, Gertz MA, Treon SP, Ansell SM, Castillo JJ, Kapoor P. Simplified Risk Stratification Model for Patients With Waldenström Macroglobulinemia. J Clin Oncol 2024; 42:2527-2536. [PMID: 38788183 PMCID: PMC11268554 DOI: 10.1200/jco.23.02066] [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: 09/23/2023] [Revised: 02/20/2024] [Accepted: 03/12/2024] [Indexed: 05/26/2024] Open
Abstract
PURPOSE Patients with Waldenström macroglobulinemia (WM) have disparate outcomes. Newer therapies have emerged since the development of International Prognostic Scoring System, and MYD88L265P mutation is now frequently assessed at diagnosis, warranting reexamination of the prognostic parameters. PATIENTS AND METHODS We reviewed records of 889 treatment-naïve patients with active WM, consecutively seen between January 01, 1996, and December 31, 2017, to identify clinical predictors of overall survival (OS) in univariate analyses. Patients with complete data for the parameters significant on the univariate analyses (n = 341) were included in a multivariable analysis to derive a prognostic model, subsequently validated in a multi-institutional cohort. RESULTS In the derivation cohort (n = 341), age (hazard ratio [HR], 1.9 [95% CI, 1.2 to 2.1]; P = .0009), serum lactate dehydrogenase (LDH) above upper limit of normal (HR, 2.3 [95% CI, 1.3 to 4.5]; P = .007), and serum albumin <3.5 g/dL (HR, 1.5 [95% CI, 0.99 to 2.3]; P = .056) were independently prognostic. By assigning a score of 1 point each to albumin <3.5 g/dL (HR, 1.5) and age 66-75 years (HR 1.4) and 2 points for age >75 years (HR, 2.6) or elevated LDH (HR, 2.3), four groups with distinct outcomes were observed on the basis of the composite scores. Five-year OS was 93% for the low-risk (score 0), 82% for low-intermediate risk (score 1), 69% for intermediate-risk (score 2), and 55% for the high-risk (score ≥3; P < .0001) groups. In the validation cohort (N = 335), the model maintained its prognostic value, with a 5-year OS of 93%, 90%, 75%, and 57% for the four groups, respectively (P < .0001). CONCLUSION Modified Staging System for WM (MSS-WM), utilizing age, albumin, and LDH is a simple, clinically useful, and externally validated prognostic model that reliably risk-stratifies patients with symptomatic WM into four groups with distinct prognosis.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Jennifer Le-Rademacher
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Eric Durot
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
| | - Shirley D’Sa
- University College of London, London, United Kingdom
| | - Jithma P. Abeykoon
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Patrizia Mondello
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Shaji Kumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Jonas Paludo
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Joselle M. Cook
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Robert A. Kyle
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Alain Delmer
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
| | | | - Morie A. Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Stephen M. Ansell
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Prashant Kapoor
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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Gertz MA. Immunoglobulin light chain amyloidosis: 2024 update on diagnosis, prognosis, and treatment. Am J Hematol 2024; 99:309-324. [PMID: 38095141 DOI: 10.1002/ajh.27177] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/21/2024]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or MGUS." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for the diagnosis of AL amyloidosis. Organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP or BNP), serum troponin T(or I), and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four stages; 5-year survivals are 82%, 62%, 34%, and 20%, respectively. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Current first-line therapy with the best outcome is daratumumab, bortezomib, cyclophosphamide, and dexamethasone. The goal of therapy is a ≥VGPR. In patients failing to achieve this depth of response options for consolidation include pomalidomide, stem cell transplantation, venetoclax, and bendamustine. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure. Trials of antibodies to deplete deposited fibrils are underway.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Buske C, Castillo JJ, Abeykoon JP, Advani R, Arulogun SO, Branagan AR, Cao X, D'Sa S, Hou J, Kapoor P, Kastritis E, Kersten MJ, LeBlond V, Leiba M, Matous JV, Paludo J, Qiu L, Tam CS, Tedeschi A, Thomas SK, Tohidi-Esfahani I, Varettoni M, Vos JM, Garcia-Sanz R, San-Miguel J, Dimopoulos MA, Treon SP, Trotman J. Report of consensus panel 1 from the 11 th International Workshop on Waldenstrom's Macroglobulinemia on management of symptomatic, treatment-naïve patients. Semin Hematol 2023; 60:73-79. [PMID: 37099027 DOI: 10.1053/j.seminhematol.2023.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
Consensus Panel 1 (CP1) of the 11th International Workshop on Waldenstrom's Macroglobulinemia (IWWM-11) was tasked with updating guidelines for the management of symptomatic, treatment-naïve patients with WM. The panel reiterated that watchful waiting remains the gold standard for asymptomatic patients without critically elevated IgM or compromised hematopoietic function. For first-line treatment, chemoimmunotherapy (CIT) regimens such as dexamethasone, cyclophosphamide, rituximab (DRC), or bendamustine, rituximab (Benda-R) continue to play a central role in managing WM, as they are effective, of fixed duration, generally well-tolerated, and affordable. Covalent BTK inhibitors (cBTKi) offer a continuous, generally well-tolerated alternative for the primary treatment of WM patients, particularly those unsuitable for CIT. In a Phase III randomized trial updated at IWWM-11, the second-generation cBTKi, zanubrutinib, was less toxic than ibrutinib and induced deeper remissions, thus categorizing zanubrutinib as a suitable treatment option in WM. While the overall findings of a prospective, randomized trial updated at IWWM-11 did not show superiority of fixed duration rituximab maintenance over observation following attainment of a major response to Benda-R induction, a subset analysis showed benefit in patients >65 years and those with a high IPPSWM score. Whenever possible, the mutational status of MYD88 and CXCR4 should be determined before treatment initiation, as alterations in these 2 genes predict sensitivity towards cBTKi activity. Treatment approaches for WM-associated cryoglobulins, cold agglutinins, AL amyloidosis, Bing-Neel syndrome (BNS), peripheral neuropathy, and hyperviscosity syndrome follow the common principle of reducing tumor and abnormal protein burden rapidly and deeply to improve symptoms. In BNS, ibrutinib can be highly active and produce durable responses. In contrast, cBTKi are not recommended for treating AL amyloidosis. The panel emphasized that continuous improvement of treatment options for symptomatic, treatment-naïve WM patients critically depends on the participation of patients in clinical trials, whenever possible.
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Affiliation(s)
- Christian Buske
- University Hospital Ulm, Institute of Experimental Cancer Research, Ulm, Germany.
| | | | | | | | | | | | - Xinxin Cao
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Marie J Kersten
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam/LYMMCARE, Amsterdam, Netherlands
| | - Veronique LeBlond
- Groupe Hospitalier Pitié-Salpêtrière, Sorbonne University, Paris France
| | - Merav Leiba
- Faculty of Health Science, Ben- Gurion University of the Negev, Israel Assuta Ashdod University Hospital; Faculty of Health Science, Ben-Gurion University of the Negev, Negev, Israel Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jeffrey V Matous
- Colorado Blood Cancer Institute, Sarah Cannon Research Institute, Denver, CO
| | | | - Lugui Qiu
- National Clinical Medical Research Center for Blood Diseases, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | | | | | | | | | - Marzia Varettoni
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Josephine M Vos
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam/LYMMCARE, Amsterdam, Netherlands
| | - Ramon Garcia-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca, CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
| | - Jesus San-Miguel
- Clínica Universidad de Navarra, Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Centro de Investigación Biomédica en Red Cáncer, Pamplona, Spain
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Steven P Treon
- Dana Farber Cancer Institute, Harvard Medical School, Boston MA
| | - Judith Trotman
- Concord Repatriation General Hospital, University of Sydney, Sydney, Australia
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