Laboratory Features of Newly Diagnosed Multiple Myeloma Patients

Changes in RDW according to prognostic predictors in newly diagnosed multiple myeloma

RDW is an erythrocyte index that increase in multiple myeloma, in which it appears to have an important role in predicting outcome. For this reason, we performed a retrospective analysis to evaluate the relationships of RDW with some important prognostic predictors. Specifically, in a cohort of 190 newly diagnosed multiple myeloma patients, we have examined the behaviour of RDW and its trend in relation to the ISS stage and other prognostic factors, such as albumin, beta-2 microglobulin, LDH and bone marrow plasma cell infiltration. We performed the analysis in the entire cohort of patients and in the three different disease isotypes (Light chain, IgA, and IgG multiple myeloma). The evaluation of RDW in the different isotypes was made with the Kruskal-Wallis test, integrated by the Dunn test. The comparison between the subgroups allocated above and below the median value of each prognostic factor, was made with the Mann-Whitney test. From our analysis, we observed that RDW is higher in the IgA multiple myeloma, and it increases significantly from ISS I to III. Moreover, RDW increases in the presence of lower albumin values, higher levels of beta2-microglobulin and LDH and in the presence of a greater bone marrow plasma cell infiltrate.

Thrombotic Risk and Calculated Whole Blood Viscosity in a Cohort of Patients With New Diagnosis of Multiple Myeloma

The pathogenesis of venous thromboembolism in multiple myeloma is still poorly understood because multiple factors are involved. In particular, the increase in whole blood viscosity has a key role and, therefore, we performed an evaluation of some hemorheological determinants in multiple myeloma patients, putting them in relation to the thrombotic risk, with the aim to evaluate if an alteration of the hemorheological pattern was associated with a higher thrombotic risk. We performed an observational retrospective cohort study with data collected from January 2017 to September 2022. In a group of 190 patients with newly diagnosed multiple myeloma, we have examined the trend of calculated blood viscosity according to the Merrill formula, and we stratified the patients for the thrombotic risk in accordance with the IMWG/NCCN guidelines and with IMPEDE VTE score. Using the thrombotic risk stratification proposed by IMWG/NCCN any variation in calculated blood viscosity is evident, while, with the IMPEDE VTE score, we observed an increase in calculated blood viscosity in patients with "intermediate + high" risk. The calculated blood viscosity is higher in subjects presenting an "intermediate + high" thrombotic risk according to the IMPEDE VTE score. This association could therefore lay the groundwork for further research with the aim to confirm the role of hemorheological pattern in MM-related thrombotic risk.

Mechanism of hyperproteinemia-induced damage to female reproduction in a genetic silkworm model

Hyperproteinemia is a metabolic disorder characterized by abnormally elevated plasma protein concentrations (PPC) in humans and animals. Here, a genetic silkworm model with high PPC was employed to investigate the effect of elevated PPC on female reproduction. Transcriptomic analysis revealed that high PPC induces downregulation of the ovarian development-related genes and disrupts ovarian sugar metabolism. Biochemical and endocrinal analyses revealed that high PPC increases trehalose and glucose levels in hemolymph and glycogen content in the fat body through activation of the gluconeogenic pathway and inhibition of the Insulin/Insulin-like growth factor signaling pathway-the serine/threonine kinase (IIS-AKT) pathway, thus disrupting characteristic metabolic homeostasis of sugar in the ovary. These resulted in ovarian developmental delay as well as reduced number and poor quality of eggs. Insulin supplementation effectively increased egg numbers by lowering blood sugar. These collective results provide new insights into the mechanisms by which high PPC negatively affects female reproduction and support the potential therapeutic effects of insulin.

Progressive multifocal leukoencephalopathy in multiple myeloma: a case report of a patient with SARS-CoV-2 infection and an updated systematic literature review

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by a reactivation of the human polyomavirus 2 (HPyV-2, previously known as JCV) in immunosuppressed individuals. Few cases of PML have been described in multiple myeloma (MM) patients.

METHODS

We described a case of PML in a patient with MM with fatal worsening that occurred during SARS-CoV-2 infection. We also performed a literature review to update the 16 cases series of MM patients with PML already collected until April 2020.

RESULTS

A 79-year-old female patient with refractory IgA lambda MM in Pomalidomide- Cyclophosphamide-Dexamethasone regimen developed gradual lower limbs and left arm paresis along with a decreased consciousness 3.5 years after the MM diagnosis. Symptoms developed shortly after the recognition of hypogammaglobulinemia. After SARS-CoV-2 infection, her neurological status quickly worsened until she deceased. MRI features and JCV-positive PCR on CSF confirmed the PML diagnosis. Our literature review adds sixteen clinical cases of PML in MM published between May 2020 and March 2023 to the 16 cases already collected in the previously published review by Koutsavlis.

DISCUSSION

PML has been increasingly described in MM patients. It remains questionable if the HPyV-2 reactivation is determined by the severity of MM itself, by the effect of drugs or by a combination of both. SARS-CoV-2 infection may have a role in worsening PML in affected patients.

Clinical Pharmacokinetics and Pharmacodynamics of Daratumumab

Daratumumab is a fully human, monoclonal immunoglobulin G1 and a first-in-class CD38-targeting drug approved by the US Food and Drug Administration for the treatment of patients with relapsed/refractory and newly diagnosed multiple myeloma or newly diagnosed light-chain amyloidosis. CD38 is heavily expressed on malignant myeloma cells, and daratumumab exerts anti-myeloma activity via immune-mediated mechanisms, direct induction of apoptosis, and immunomodulation. Daratumumab is used as monotherapy or in combination with standard-of-care myeloma therapies, including proteasome inhibitors, immunomodulatory agents, DNA-alkylating agents, and corticosteroids. Following an intravenous infusion, daratumumab exhibits nonlinear pharmacokinetics (PK), as clearance decreases with higher doses and over time because of target-mediated effects. Dosing schedules vary depending on indications and co-administered drugs, but generally daratumumab is administered weekly for 6-9 weeks followed by a less frequent dosing regimen, once every 2-4 weeks. Daratumumab exposure is strongly correlated with efficacy, and the exposure-efficacy relationship follows a maximal effect model, whereas exposure is not correlated with safety endpoints. The approved dose of 16 mg/kg of daratumumab results in the saturation of 99% of the target at the end of weekly dosing in most patients, and high target saturation is maintained over time during the less frequent dosing schedule. Infusion-related reactions are frequently observed in patients given daratumumab, particularly with the first infusion, thus prompting long durations of infusion (~ 7 h) and splitting of the first dose across 2 days. This led to the development of a subcutaneous delivery formulation for daratumumab (Dara-SC). Dara-SC provides a similar efficacy and safety profile to intravenous daratumumab (Dara-IV) but has a much lower rate of infusion-related reactions and a shorter infusion time. Exposure-response relationships for efficacy and safety endpoints were similar between Dara-SC and Dara-IV, and co-administered drugs with either Dara-IV or Dara-SC do not significantly affect daratumumab PK. Except for baseline myeloma type and albumin level, none of the other investigated disease and patient characteristics (renal/hepatic function, age, sex, race, weight, Eastern Cooperative Oncology Group performance status) was identified to have clinically relevant effects on exposure to daratumumab monotherapy or combination therapy regimens. Dara-IV exposure was significantly lower in patients with immunoglobulin G myeloma compared with patients with non-immunoglobulin G myeloma (p < 0.0001) and in patients with a lower albumin level, whereas the overall response rate was similar regardless of the myeloma type and albumin level. Daratumumab dose adjustment is not currently recommended based on disease and patient characteristics.

Characteristics of inpatients with newly diagnosed multiple myeloma in hematology, nephrology, and orthopedic departments

To describe the characteristics of multiple myeloma (MM) by retrospectively analyzing data from patients with MM in hematology, nephrology, and orthopedic departments, we selected inpatients diagnosed with MM for the first time who were admitted to the hematology department of Taizhou Hospital of Zhejiang Province between January 1, 2017, and June 30, 2021 ([Formula: see text]) and those admitted to the nephrology ([Formula: see text]) and orthopedic ([Formula: see text]) departments of Taizhou Hospital of Zhejiang Province between January 1, 2010, and June 30, 2021. For patients with MM initially diagnosed in the nephrology or orthopedic departments, age- and sex-matched patients without MM were randomly selected in a 1:1 ratio. Conditional logistic regression models were used to assess the risk of MM in hospitalized patients in the nephrology and orthopedic departments. This study included 200 patients, with a median age of 65 years. There were differences among patients in the three departments with respect to fracture, degree of anemia, proteinuria levels, red blood cell (RBC) count, hemoglobin levels, total protein (TP) levels, albumin levels, and laboratory indicators of renal function. TP levels > 68.45 g/L were independent risk factors for patients in the nephrology department (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 1.001-1.024, P = 0.04), and RBC count < 3.79 × 10¹²/L was an independent risk factor for orthopedic inpatients (OR = 0.49, 95% CI 0.268-0.913, P = 0.02). Therefore, nephrologists should pay attention to the TP level of hospitalized patients to facilitate the early identification of MM in patients with chronic kidney disease. Orthopedic surgeons should pay attention to RBC counts in patients with fractures, and patients with low RBC counts should avoid unnecessary surgery and move to specialist care as early as possible.

Cross-Sectional and Longitudinal Associations Between the Serum G\lobulin Level, and Renal Impairment and All-Cause Deaths in Chinese Patients With Newly Diagnosed Multiple Myeloma

Background

A large number of studies have shown that serum globulin plays an important role in a variety of cancers; However, few studies have identified the association between serum globulin levels and end-stage renal disease (ESRD) and all-cause death in Chinese patients with multiple myeloma (MM).

Methods

A generalized additive model and smooth curve fitting were fitted to assess the cross-sectional relationship between the serum globulin levels and renal impairment (RI) at baseline. Multivariate-adjusted Cox regression models were performed to determine the associations between the baseline serum globulin levels and the onset of all-cause death and ESRD in patients with MM.

Results

288 participants who were followed for > 3 months were eligible for the retrospective study. The median serum globulin level was 5.1 ± 2.6 mg/dL. The average follow-up time was 23.3 months. Thirty-two patients (11.5%) had ESRD and 24 patients (8.33%) died after diagnosis. In patients with a serum globulin level < 6.1 mg/dL, the serum globulin level had an independent, negative correlation with the occurrence of MM-related RI. Patients were divided into three groups on the basis of serum globulin tertiles: low (L group), 3.3 mg/dL; middle (M group), 3.3-6.0 mg/dL; and high (H group), 6.0 mg/dL. Cox regression analysis showed that low serum globulin levels may be independent risk factors for all-cause death and the occurrence of ESRD in patients with MM; however, an elevated baseline serum globulin can predict all-cause deaths in patients with MM, but cannot predict the onset of ESRD.

Conclusions

This observational study suggested that there was a non-linear relationship between the serum globulin level and the occurrence of RI in patients with MM. This finding showed that the serum globulin level had a U-shaped association with all-cause death and an L-shaped association with ESRD in patients with MM.

Analysis of Serum IgG1 to Predict Progression and Therapeutic Effect in Patients with Multiple Myeloma

Objective

The correlation between laboratory indicators and clinical treatment effects and the prognosis of multiple myeloma remains poorly understood. Therefore, our study investigated whether serum IgG subclasses could be employed as potential indicators contributed to evaluate the therapeutic effect and prognosis of patients with multiple myeloma. Patients and Methods. Records of patients with multiple myeloma were initially diagnosed at the First Affiliated Hospital of Soochow University, China, from August 1, 2017, to February 28, 2020. The assessment abilities of serological indicators for therapeutic effect were evaluated in patients compared with healthy controls.

Results

In 560 study patients with multiple myeloma, serum IgA, IgG, IgM, κ-LC, and λ-LC increased by15%, 33.04%, 1.96%, 27.50%, and 26.43%, respectively. Further analysis found that IgG1, IgG2, IgG3, and IgG4 were over the upper limit of the reference range with 26.38%, 6.09%, 8.12%, and 4.64%, respectively. κ-LC and λ-LC were found in the urine in 65.13% and 29.70%, respectively. In peripheral blood, the proportion of CD3⁺CD4⁺, CD3⁻CD19⁺ cells, and CD4⁺/CD8⁺ decreased, whereas CD3⁺CD8⁺ cells and CD16⁺/CD56⁺ increased, and the associated cytokines IL-2, IL-4, IL-6, TNF-α, and IFN-γ were upregulated in patients when compared with healthy controls. Furthermore, the serum levels of IgA, IgG, IgG1, IgG2, IgG3, and IgG4 gradually decreased in patients before, during, and after treatment. Similar results were found in serum and urine κ-LC and λ-LC.

Conclusion

Serum IgG1 level could serve as the potential indicator for evaluating the therapeutic effect for patients with multiple myeloma. κ-LC and λ-LC also have the potential to be prognostic indicators. More studies are warranted to explore these serological indicators for personalized therapy in the future.

Survival Outcomes of Newly Diagnosed Multiple Myeloma at a Tertiary Care Center in North India (IMAGe: 001A Study)

PURPOSE

The outcomes of patients with myeloma from developing countries are often lacking because of poor record maintenance. Publications from such settings are also limited because of the retrospective nature of the data collection. Information technology can bridge these gaps in developing countries with real-time data maintenance. We present the real-time survival data of the patients with myeloma from a tertiary care center in North India using one such indigenously built software.

PATIENTS AND METHODS

These are real-time data of all patients with myeloma presenting to a tertiary care center from North India. The patient characteristics (demographics, baseline disease characteristics, risk stratification, and outcomes) were recorded contemporaneously. The survival of the study population was analyzed and grouped based on various disease characteristics at diagnosis.

RESULTS

The median age of the study population (N = 696) was 65.9 (34.9-94.9) years with male predominance (65%). The median follow-up was 3.7 years (0-18.6 years) with the median overall survival (OS) not achieved. The OS of the study population at 1, 3, and 5 years was 94% (n = 558), 87.5% (n = 394), and 83.1% (n = 267), respectively. Most of the patients presented in advanced stages based on International Staging System (III:70%). On Kaplan-Meier analysis, the presence of weight loss (P = .01), renal dysfunction (P = .047), and anemia at diagnosis (P = .004) had a significant impact on survival. On Cox proportional model univariate analysis, the presence of renal dysfunction, anemia, and weight loss had the significant hazard ratio of 1.68 (1-2.82, P = .049), 3.18 (1.39-7.29, P = .0063), and 2.81 (1.22-6.42, P = .014), respectively, whereas on multivariate analysis of hypercalcemia, renal disease, anemia, and bone disease (CRAB) features, only anemia was found to have a significant hazard ratio of 2.56 (1.01-6.47, P = .046).

CONCLUSION

The real-world data show OS comparable with the published western literature. Only anemia was found to have significant impact on survival. The use of such software can aid in better data-keeping in resource-constrained settings.

MicroRNAs as a Potential New Preventive Approach in the Transition from Asymptomatic to Symptomatic Multiple Myeloma Disease

Simple Summary

Multiple myeloma (MM) is the second most common haematologic malignancy, and it remains an incurable disease despite the advances of novel therapies. It is characterised by a multistep process that arises from a pre-malignant asymptomatic status-defined monoclonal gammopathy of undetermined significance (MGUS), evolves to a middle stage named smouldering myeloma phase (SMM), and culminates in the active disease (MM). Identification of early and non-invasive markers of the disease progression is currently an active field of investigation. In this review, we discuss the role and significance of microRNAs (miRNAs) as potential diagnostic biomarkers to predict the clinical transition from MGUS/SMM status to MM.

Abstract

Multiple myeloma (MM) is a hematological malignancy characterised by proliferation of clonal plasma cells (PCs) within the bone marrow (BM). Myelomagenesis is a multi-step process which goes from an asymptomatic phase, defined as monoclonal gammopathy of undetermined significance (MGUS), to a smouldering myeloma (SMM) stage, to a final active MM disease, characterised by hypercalcemia, renal failure, bone lesions anemia, and higher risk of infections. Overall, microRNAs (miRNAs) have shown to significantly impact on MM tumorigenesis, as a result of miRNA-dependent modulation of genes involved in pathways known to be crucial for MM pathogenesis and disease progression. We aim to revise the literature related to the role of miRNAs as potential diagnostic and prognostic biomarkers, thus highlighting their key role as novel players within the field of MM and related premalignant conditions.

Usefulness of albumin-globulin ratio as a clinical prognostic factor in patients with thyroid cancer treated with radioiodine

OBJECTIVE

Albumin-globulin ratio (AGR), which is calculated by dividing serum albumin by serum globulin, is considered as a cancer-related inflammation biomarker. Although the prognosis of many solid cancers has been shown to be associated with AGR, there are no studies to demonstrate the association between the prognosis of thyroid cancer and AGR. The purpose of this study is to reveal the relationship between AGR and overall survival (OS) in patients with thyroid cancer who received radioactive iodine therapy (RIT).

METHODS

Eighty-eight patients with thyroid cancer who had received RIT for the first time in our institution were included. The values before RIT were adopted as initial measurements for serum albumin, globulin, and thyroglobulin (Tg) and used for analysis. Patients were divided into two groups based on the AGR value. We analyzed the relationship between clinical factors and treatment outcome.

RESULTS

The median follow-up period was 92.4 months (range: 30.1-173.9 months). The 5-year OS and progression-free survival (PFS) were 94% and 54%, respectively. Seventeen patients (< 65 years, 8; and ≥ 65 years, 9) died during the follow-up period. Low AGR was significantly associated with OS in both univariate and multivariate analyses (p = 0.0059 and p = 0.0120, respectively). As the 5-year OS was as high as 94%, there was no significant difference in survival rate between the two groups during the first 5 years. However, there seemed to be a remarkable difference in 10 years after the first RIT. On the other hand, Tg was significantly associated with PFS in both univariate and multivariate analyses (p = 0.0016 and p = 0.0441, respectively). In patients under the age of 65, the PFS rate was significantly lower in the low AGR group (p < 0.0001), while there was no difference in PFS rate between the two AGR groups in patients aged 65 years or older.

CONCLUSIONS

AGR may be used as a prognostic factor in relatively younger patients with thyroid cancer treated with radioiodine, while it may be less useful in the older. Overall, it may be an independent prognostic factor for long-term survival in those with thyroid cancer.

Influence of Hyperproteinemia on Insect Innate Immune Function of the Circulatory System in Bombyx mori

Simple Summary

Hyperproteinemia, a condition of elevated protein levels in the blood, is associated with a diverse range of human and animal diseases. However, there is no reliable hyperproteinemia disease models or modeling methods in mammal or other organisms, and the effect of hyperproteinemia on immunity is still unknown. Our work succeeded in constructing an animal model of hyperproteinemia with no primary disease effects and a controllable plasma protein concentration (PPC) in an invertebrate model organism, Bombyx mori. Our work confirmed that high PPC enhances hemolymph phagocytosis via a rapid increase in granulocytes and inhibited hemolymph melanization due to inhibition of the prophenoloxidase (PPO) signaling pathway, and also upregulated the gene expression of antimicrobial peptides via activating the Toll and Imd pathways in NF-κB signaling, and showed an inconsistent antibacterial activity for Gram-positive and Gram-negative bacteria. Our results show that high PPC had multiple significant effects on the innate immune function of the silkworm circulatory system and is expected to be improved by endocrine hormones. Our work explores the pathogenesis of hyperproteinemia in an invertebrate model, and expands the scope for silkworm biomedical applications, even use for a potential drug development platform.

Abstract

Metabolic disorders of the circulatory system of animals (e.g., hyperglycemia and hyperlipidemia) can significantly affect immune function; however, since there is currently no reliable animal model for hyperproteinemia, its effects on immunity remain unclear. In this study, we established an animal model for hyperproteinemia in an invertebrate silkworm model, with a controllable plasma protein concentration (PPC) and no primary disease effects. We evaluated the influence of hyperproteinemia on innate immunity. The results showed that high PPC enhanced hemolymph phagocytosis via inducing a rapid increase in granulocytes. Moreover, while oenocytoids increased, the plasmacytes quickly dwindled. High PPC inhibited hemolymph melanization due to decreased phenoloxidase (PO) activity in the hemolymph via inhibiting the expression of the prophenoloxidase-encoding genes, PPO1 and PPO2. High PPC upregulated the gene expression of antimicrobial peptides via differential activation of the Toll and Imd signaling pathways associated with NF-κB signaling, followed by an induction of inconsistent antibacterial activity towards Gram-positive and Gram-negative bacteria in an animal model of high PPC. Therefore, high PPC has multiple significant effects on the innate immune function of the silkworm circulatory system.