Report of consensus panel 5 from the 11th international workshop on Waldenstrom's macroglobulinemia on COVID-19 prophylaxis and management

Consensus Panel 5 (CP5) of the 11th International Workshop on Waldenstrom's Macroglobulinemia (IWWM-11; held in October 2022) was tasked with reviewing the current data on the coronavirus disease-2019 (COVID-19) prophylaxis and management in patients with Waldenstrom's Macroglobulinemia (WM). The key recommendations from IWWM-11 CP5 included the following: Booster vaccines for SARS-CoV-2 should be recommended to all patients with WM. Variant-specific booster vaccines, such as the bivalent vaccine for the ancestral Wuhan strain and the Omicron BA.4.5 strain, are important as novel mutants emerge and become dominant in the community. A temporary interruption in Bruton's Tyrosine Kinase-inhibitor (BTKi) or chemoimmunotherapy before vaccination might be considered. Patients under treatment with rituximab or BTK-inhibitors have lower antibody responses against SARS-CoV-2; thus, they should continue to follow preventive measures, including mask wearing and avoiding crowded places. Patients with WM are candidates for preexposure prophylaxis, if available and relevant to the dominant SARS-CoV-2 strains in a specific area. Oral antivirals should be offered to all symptomatic WM patients with mild to moderate COVID-19 regardless of vaccination, disease status or treatment, as soon as possible after the positive test and within 5 days of COVID-19-related symptom onset. Coadministration of ibrutinib or venetoclax with ritonavir should be avoided. In these patients, remdesivir offers an effective alternative. Patients with asymptomatic or oligosymptomatic COVID-19 should not interrupt treatment with a BTK inhibitor. Infection prophylaxis is essential in patients with WM and include general preventive measures, prophylaxis with antivirals and vaccination against common pathogens including SARS-CoV-2, influenza, and S. pneumoniae.

HEMOSTASIS DISORDERS IN CORONARY ARTERY DISEASE: A PROSPECTIVE COMPARATIVE STUDY OF 130 PATIENTS

The laboratory detection of factors that participate in coagulation mechanisms in patients with coronary heart disease may lead to important findings regarding the contribution of endothelial function to atherosclerotic lesions of coronary arteries. The main purpose of this study was to investigate the role of high-sensitivity C-reactive protein (hs-CRP), von Willebrand factor (vWF) activity, thrombomodulin (TM), ADAMTS13 activity and myeloperoxidase (MPO) in patients undergoing coronary angiography due to non-ST-elevation myocardial infarction (NSTEMI), unstable angina (UA) and stable angina pectoris with positive stress testing-induced myocardial ischemia (controls). Furthermore, the measured biomarkers were examined among patients with classical cardiovascular risk factors. 50 NSTEMI patients, 50 UA patients and 30 controls referred to coronary angiography were included in the study. The blood samples were collected before the catheter procedure. MPO, TM and ADAMTS13 activity were measured by enzyme-linked immunosorbent assay (ELISA), while vWF activity was calculated with INNOVANCE vWF Ac. When the laboratory results were compared between the three study groups, hs-CRP was found to be higher in NSTEMI patients compared to UA patients (p=0.0015) and controls (p<0.0001). ADAMTS13 activity was higher in NSTEMI (p=0.0035) and UA patients (p=0.0102) compared to controls and TM was lower in NSTEMI patients compared to UA patients (p=0.0307) and controls (p=0.0002). Moreover, MPO was higher in UA patients compared to the control group (p=0.0227). Finally, each of the aforementioned biomarkers was compared in the presence of the following cardiovascular risk factors: smoking, diabetes mellitus, arterial hypertension, dyslipidemia, chronic kidney disease (CKD) and peripheral artery disease (PAD). The results of this study add more data to the current medical literature concerning the role of coagulation disorders, endothelial damage and immunothrombosis in patients with coronary artery disease and their correlation with traditional risk factors for cardiovascular disease.

Understanding the molecular mosaic of cardiotoxicity of light chains in plasma cell dyscrasias and cardiac light chain amyloidosis with the use of patient derived full-length light chains

Background

Cardiac light chain amyloidosis (AL-CA) is a life-threatening disease and the major determinant of prognosis in AL amyloidosis. The management of heart failure (HF) in AL is challenging and gold standard therapies for HF are poorly tolerated or ineffective. Cardiac toxicity of LCs in AL-CA is poorly understood and the comparison of cardiotoxicity of LCs derived from plasma cell dyscrasias (PCDs) such as multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS), will improve our understanding of the mechanisms of cardiac damage.

Purpose

We aimed to 1) genetically identify and biotechnologically produce full-length LCs from patients with AL-CA, MM, MGUS or non-clonal LCs from healthy volunteers (HV), 2) identify LCs' cardiotoxicity and 3) investigate the underlying mechanisms of cardiotoxicity in vitro.

Methods

Bone marrow derived CD138+ cells from n=7 patients with AL-CA, n=2 patients with MM and n=2 patients with MGUS and peripheral blood mononuclear cells (PBMCs) from n=2 HV were isolated for RNA extraction and characterization of the LC gene family repertoire. At the protein level, LC expression was confirmed by immunoprecipitation in patients' serum followed by top-down proteomics. The overexpressed LC genes in each patient, encoding the full-length clonal LCs were cloned and produced in Shuffle E. coli cells. Two LCs were produced from HV based on the primary protein structure similarity with the patients' LCs. Primary adult ventricular murine cardiomyocytes (pAVMCs) were isolated and exposed at various LC concentrations for evaluation of cell death and investigation of the cardiotoxicity mechanisms via gene and protein expression. LCs folding, oligomerization and amyloidogenic potential were assessed via circular dichroism (CD), SDS page and electron microscopy respectively.

Results

We successfully identified the LCs responsible for the disease and isolated the respective proteins in all cases (7 AL-CA, 2 MM, 2 MGUS and 3 HV). Despite the similarity of the LCs in conformation as beta-sheet and oligomerization mainly as dimers, 5 out of 7 AL-CA derived LCs led to a different extent of cardiotoxicity in pAVMCs compared to the HV, MM and MGUS derived LCs which did not alter cell viability. Interestingly, these 5 LCs bared the highest amyloidogenic potency. LCs induced different molecular responses leading to cardiomyocyte death. AL-CA proteins κ-type induced apoptosis and overexpression of endoplasmic reticulum stress (ERS) markers while LCs λ-type increased unfolded protein response (UPR) markers and autophagy without inducing apoptosis. All LCs of κ-type including from MM and MGUS patients led to inteleukin-6 mediated inflammation indicating that this mechanism is independent of the observed toxicity.

Conclusions

AL-CA derived LCs induce cardiotoxicity, which correlates to their amyloidogenic potential via ERS, UPR, autophagy and apoptosis which can be considered targets for cardioprotection.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Hellenic Foundation for Research and Innovation

Sustained vasodilation after cold pressor test is an independent predictor of poor survival in primary AL amyloidosis

Background

Primary AL amyloidosis is a rare yet lethal systemic disorder. Dysfunction of the autonomous nervous system due to disease-related nerve infiltration is a common manifestation of AL amyloidosis. Previously published own work indicated that AL patients present sustained paradoxical vasodilation in response to sympathetic stimulus, as assessed by cold pressor test (CPT). The clinical relevance of this finding is unknown.

Purpose

We sought to investigate the relationship between CPT-induced vascular response and mortality in AL amyloidosis.

Methods

We consecutively recruited 97 newly diagnosed patients with AL amyloidosis. CPT of the brachial artery was performed before treatment initiation. All measurements were assessed using high resolution ultrasonography (14.0Mhz multifrequency linear array probe, Vivid 7 Pro; General Electric Healthcare, Milwaukee, Wisconsin, USA). The maximum vasodilation of the brachial artery was measured during the sympathetic stimulus and 3 minutes after withdrawal (sustained response). All-cause mortality was defined as the primary end-point of the study.

Results

Mean age was 66 years with prevalence of male gender. Sustained vasodilation (but not vasodilation during CPT) was associated with heart failure, NYHA stage, BNP and peripheral vascular involvement (p&lt;0.05 for all). Sustained vasodilation after withdrawal of the sympathetic stimulus was significantly associated with mortality as assessed by Cox regression analysis (HR: 1.149, 95% CI 1.042–1.269, p=0.005). This association remained significant after adjustment for age, sex, systolic blood pressure (SBP), nerve involvement and Mayo stage (HR: 1.123, 95% CI 1.014–1.243, p=0.026). A sustained vasodilation ≥3.35% from pre-stimulus diameter was associated with shorter survival (log-rank test, p=0.022, Figure 1). No association between vasodilation during sympathetic stress and mortality was observed.

Conclusions

In AL amyloidosis, sustained paradoxical vasodilation in response to sympathetic stimulus was associated with poor survival. The clinical utility of this index of vascular autonomic dysfunction as a potential prognostic and therapeutic biomarker in AL amyloidosis merits further investigation.

Funding Acknowledgement

Type of funding sources: None.

Mineralocorticoid receptor signaling is implicated in carfilzomib-induced increase in blood pressure

Introduction

Carfilzomib (Cfz), an irreversible proteasome inhibitor, is a first line antineoplastic agent indicated for relapsed/refractory multiple myeloma, with its clinical use being hampered by cardiovascular adverse effects. Hypertension, is the most common cardiovascular side effect of Cfz, remaining of unknown pathogenicity.

Purpose

Considering that management of Cfz-related hypertension remains an unmet clinical need and that renal function plays a pivotal role in blood pressure regulation we sought to investigate the renal contribution in Cfz-induced hypertension.

Methods

We have previously established a translational model of Cfz-induced cardiomyopathy, based on clinically applicable dose regimens and we have concluded that two and four dose protocols successfully resemble the clinical observations in vivo. Herein, sixty C57Bl/6 male mice (12–14 weeks old) were randomized to: 1. Two doses Protocol: i. Control (N/S 0.9%), ii. Cfz (8mg/kg) for two consecutive days; and 2. Four doses Protocol: i. Control (N/S 0.9%), ii. Cfz (8mg/kg) for seven days intraperitoneally. Systolic (SBP) and diastolic blood pressure (DBP) were measured by tail cuffs; the latter protocol was repeated and urine collection was performed via metabolic cages studies. Renal samples were collected for histological, proteomic, metabolomic and molecular signaling analyses. Finally, eplerenone, a mineralocorticoid receptor (MR) blocker, was orally co-administered with Cfz to the mice daily (165 mg/kg) in the four doses protocol.

Results

Cfz increased SBP only in the four doses protocol (78.50±2.05 vs 68.20±0.73 in the Control group, **P&lt;0.01). Histological evaluation of the kidneys revealed a juxtaglomerular apparatus hyperplasia (JAH) in the same dose regimen. Proteomic analysis presented that metabolic and transport of small molecules pathways were differentially regulated in the Cfz treated murine kidneys. Metabolomic analysis revealed an increase in urea cycle metabolites (L-Alanine, L-Glutamine, glutamate, aspartate) and taurine content in the kidneys. Additionally, mice presented decreased diuresis without any differences in other metabolic parameters. In parallel an upregulation of β-ENaC expression and activation of MR/SGK-1 signaling in the kidneys was observed, indicating that Cfz activates MR signaling. Co-administration of eplerenone and Cfz, restored diuresis, decreased SBP and inhibited MR/SGK-1 signaling in the kidneys.

Conclusions

Activation of MR signaling by Cfz in the kidneys orchestrates renal water/salt retention and drives an increase in blood pressure in vivo. Histological and metabolomic analyses present that Cfz induces an acute kidney injury and a tonicity increase. Eplerenone reversed Cfz-induced blood pressure increase and restored diuresis by inhibiting MR/SGK-1 signaling. Therefore, MR blockade emerges as a potent therapeutic approach against Cfz-related cardiovascular adverse events.

Funding Acknowledgement

Type of funding sources: None.

Peripheral vascular involvement in transthyretin cardiac amyloidosis. A comparative analysis with AL amyloidosis

Background

The pattern of peripheral vascular involvement in the wild type transthyretin-related cardiac amyloidosis (ATTRwt) and its diagnostic utility in differentiating this infiltrating cardiomyopathy from light chain (AL) cardiac amyloidosis (AL-CA) and heart failure with preserved ejection fraction (HFpEF) of different origin have not been explored.

Aims

To characterize the pattern of peripheral vascular involvement in ATTRwt and evaluate its value in differentiating ATTRwt from AL-CA and HFpEF.

Methods

Newly diagnosed patients with ATTRwt (n=42) were consecutively recruited from our amyloidosis center. These patients were matched 1:1 for age and sex to patients with AL-CA (n=32) and subjects without amyloidosis (n=32) and also matched 2:1 to HFpEF patients (n=16). All subjects underwent a series of non-invasive vascular examinations for the assessment of: 1. subclinical carotid atherosclerosis with B-mode ultrasonography, 2. Arterial stiffness with measurement of carotid-femoral pulse wave velocity, 3. Reactive vasodilation with flow-mediated dilation (FMD) and 4. Aortic blood pressures and arterial wave reflections with augmentation index (AI) and return time of reflected wave (Tr).

Results

ATTRwt patients had lower peripheral (pBP) and aortic blood pressure (aBP) markers compared to non-AL controls (p&lt;0.05 for all). ATTRwt grouping was an independent determinant of these markers, after adjustment for cardiovascular risk factors (CVRF), including history of hypertension, hyperlipidemia and diabetes, glomerular filtration rate, body mass index and smoking status (core model). ATTRwt had lower aDBP and increased Tr compared to AL subjects. In a comparison between ATTRwt and AL patients with cardiac involvement, AI and Tr were higher and FMD lower in ATTRwt patients. ATTRwt was an independent determinant of these markers, after adjustment for the core model (p&lt;0.05 for all). Compared to HFpEF, patients with ATTRwt had lower peripheral and central BP and higher Tr (p&lt;0.05 for all). By ROC analysis, Tr provided high diagnostic value for ATTRwt vs. AL-CA (Area Under the Curve, AUC=0.809, CI: 0.65–0.96) and for ATTRwt vs combined AL-CA and HFpEF (AUC=0.880, CI: 0.79–0.97). Finally, AI was closely correlated with posterior (Spearman's Rho=−0.30) and intraventricular wall thickness (Rho=−0.329) and left ventricular global longitudinal strain (Rho=−0.4) and lower cDBP with higher Gilmore and New York Heart Association stage (p&lt;0.05).

Conclusion

ATTRwt patients present differential characteristics of peripheral vascular function and aortic hemodynamics as compared to AL, HFpEF and healthy controls. The clinical value of these characteristics merit further investigation since differential diagnosis among amyloidosis types is clinically challenging, while it may have prognostic implications.

Funding Acknowledgement

Type of funding sources: None.

Global deterioration of cardiovascular mechanics by carfilzomib treatment is associated with proteasome activity in patients with relapsed multiple myeloma

Background

Carfilzomib (CFZ) is a second generation irreversible proteasome inhibitor that has been shown to improve overall survival in patients with relapsed or refractory multiple myeloma (MM) but is associated with cardiac toxicity in MM. Because ubiquitin-proteasome system (UPS) is involved in cardiovascular homeostasis exploring the effects of proteasome inhibition on cardiac mechanics, in a clinical setting, would provide novel insight of the clinical role of UPS in cardiovascular disease.

Aim

To gain a thorough understanding of proteasome inhibition on myocardial mechanics in a clinical setting.

Methods

We prospectively evaluated 48 patients with relapsed or refractory MM and an indication to receive CFZ treatment [median age: 67.5, interquartile range (64–73), 66.7% men]. All patients underwent cardiac ultrasonography at an initial visit, at the first day of the 3rd month (C3D1, n=25) and at the last day of cycle 6 (C6D16, n=48). Pulse wave velocity (PWV) was used to assess arterial stiffness and calculate arterial-ventricular coupling (VAC) by the ratio (PWV/global longitudinal strain (GLS)). Carfilzomib was administered at 27mg/m2 on days 1 (C1D1) and 2 (C1D2) of cycle 1 and at 56mg/m2 thereafter. Blood was drawn at baseline, C3D1 and C6D16 to measure proteasome activity (PrA). Patients were followed up for carfilzomib–related cardiovascular adverse events.

Results

Regarding systolic function, between baseline and C6D16, we noticed deterioration in left ventricular ejection fraction (LVEF) (57.7±5.4% vs 56.1±7.19%, p=0.022), GLS (−20.51±2.78 vs −18.88±3.45%, p=0.003), S wave of LV longitudinal strain rate and radial strain (p&lt;0.05 for both). Markers of LV diastolic function also deteriorated at 6 months including early diastolic (Ea) mitral annular velocity (7.27±1.83cm/sec vs 6.7±1.64cm/sec, p=0.008) and E wave of LV longitudinal strain rate (1.1±0.37sec-1 vs 0.95±0.36sec-1, p=0.010). Left atrial volume (LAV) and index (LAVi) increased both at 3 and 6 months (p&lt;0.05). Peak LA strain at reservoir phase (peak atrial longitudinal strain, PALS) was also decreased at 6th and 3rd month measurements (p&lt;0.05), whereas LA strain rate at reservoir function (s wave) was decreased, compared to baseline, only at 6th month (p=0.001). RV longitudinal strain also decreased between 3rd and 6th month (p=0.039). Furthermore, PWV/GLS also deteriorated at 6 months (−0.56±0.13 vs −0.64±0.21, p=0.001). By linear mixed models analysis, we found that changes in proteasome activity were associated with changes in PWV/GLS (p=0.017), LAV (p=0.015) and LAVi (p=0.009), and PALS (p=0.014).

Conclusion

CFZ treatment was associated with global deterioration of markers of myocardial systolic and diastolic function and VAC. The observed association of changes in proteasome activity with VAC and left atrial function and structure supports a direct effect of proteasome inhibition on the cross-talk between LV and arterial function and LV diastolic function.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Aortic hemodynamic parameters as predictors of incident or deteriorating hypertension during carfilzomib therapy in patients with relapsed multiple myeloma

Background

Carfilzomib (CFZ) improves survival in relapsed/refractory multiple myeloma but is associated with cardiovascular adverse events, among which hypertension is commonly reported.

Purpose

To evaluate aortic hemodynamics as possible predictors for CFZ-associated hypertension.

Methods

In a prospective study of 48 patients treated with Kd (CFZ 20/56 mg/m2 and dexamethasone) followed until disease progression or cycle 6 for a median of 10 months, patients underwent peripheral hemodynamic assessment, including applanation tonometry, which allows estimation of aortic blood pressure and arterial wave reflections and assessment of pulse wave velocity, which allows estimation of aortic stiffness. Hemodynamic parameters were examined at baseline and at pre-specified time points before and 24 hours after drug infusion.

Results

Thirteen patients (27.1%) developed hypertension or merited more intensive anti-hypertensive treatment (grade I or II: 6.25%, grade III: 20.8%). Patients with new onset or worsening hypertension had increased aortic [130±12.9 mmHg versus 115±16.7 mmHg, p=0.004] and peripheral systolic blood pressure (SBP) [145±15.7 mmHg versus 130±19.5 mmHg, p=0.001] at baseline. Patients distributed at highest tertile of baseline aortic SBP (log-rank test p=0.0001, Figure) or baseline peripheral SBP (log-rank test p=0.002) had significantly higher risk for CFZ associated hypertension as compared to those distributed at lower tertiles. After adjustment for age, gender and baseline hypertension, increased aortic [HR=8.0, 95% CIs 2.4–26.6, p=0.001] and peripheral SBP [HR=4.85, 95% CIs 1.53–15.4, p=0.007] remained significantly associated with hypertension. After adjustment for both baseline peripheral and aortic SBP in the same multivariable core model, aortic SBP was the only independent predictor of the study outcome (p=0.041). Accordingly, baseline aortic SBP was associated with higher discriminative value as compared to peripheral SBP [AUC: 0.819, 95% CIs 0.722–0.916 versus 0.724, 95% CIs 0.570–0.878, respectively]. Further adjustment for all cardiotoxicity risk factors using forced inclusion in non-parsimonious multivariable Cox regression models, revealed that increased aortic and peripheral SBP remained independent predictors of hypertensive events (p&lt;0.05 for both).

Conclusion

Baseline aortic hemodynamics are associated with hypertension during CFZ treatment. Aortic SBP at baseline was the strongest predictor of CFZ-associated hypertensive adverse events, suggesting that an initial assessment of aortic blood pressure may facilitate discrimination of patients in need of close monitoring during treatment.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Funding from the Hellenic Foundation for Research and Innovation (HFRI) and the General Secretariat for Research and Technology (GSRT), under grant agreement No [1285].

Al amyloidosis with cardiac involvement: cardiotoxicity of aggregation prone peptides deriving from variable domains of immunoglobulin light chains

Background/Introduction

Light chain (AL) amyloidosis is an uncommon malignancy manifested by systemic extracellular deposition of immunoglobulin light chain fibrils. The cardiac phenotype is characterised by ventricular wall thickening and stands as the most prominent cause of morbidity and mortality. Although, it has been established that the circulating light chains directly impair cardiomyocyte function, the cytotoxic effect of specific amyloidogenic peptides that may appear due to excessive cleavage of light chains remains unspecified.

Purpose

In the present work, we aimed to detect amyloidogenic “hot-spots” on the variable domains of light chains associated with cardiac AL amyloidosis (IGLV1-44 and IGLV3-01) or inferior outcomes (IGLV6-57) and define their cytotoxic effect in vitro.

Methods

At first, we used the curated database ALBase and we performed a multiple sequence alignment of the IGLV1-44, IGLV3-01 and IGLV6-57 inputs that derived only from patients with AL amyloidosis. “Aggregation-prone” hot-spots in the conserved amino acid sequences were identified with the aid of AMYLPRED2, a tool which combines 11 independent computational methods and provides a consensus result of potent amyloidogenic regions. Five peptides were rationally selected and synthetically produced in order to be tested in vitro. The amyloidogenic properties of the peptides were evaluated with Transmission Electron Microscopy and Congo red staining, while the rate of fibril formation at lower concentrations was monitored with Thioflavin T and confirmed with Scanning Electron Microscopy. In order to assess the cytotoxic effect of the non-polymerized peptides, H9C2 cells were incubated with the peptides for 24 hours at 200μg/mL and 100μg/mL and cell death was determined by lactate dehydrogenase release assay.

Results

Interestingly, sequence alignment on the variable domains of cardiac related light chains revealed the presence of several conserved domains in patients with AL amyloidosis. The chosen peptides were proven to be amyloidogenic suggesting that the variable domains share common amyloidogenic cores. Treatment of H9C2 cells with the peptides at 200μg/mL led to significant reduction in cell viability compared to vehicle treated cells (p&lt;0.001). Two of the peptides deriving from the IGLV6-57 and IGLV3-01 significantly increased cell death at 100μg/mL (p&lt;0.01 and p&lt;0.001 respectively). During the 24h treatment the tested peptides comprised of soluble species and not amyloid fibrils suggesting that monomeric and oligomeric intermediates are highly toxic.

Conclusion

We discovered five novel amyloidogenic prone regions of cardiac related variable domains that are associated with cellular toxicity and could be exploited for targeted therapeutic interventions.

Funding Acknowledgement

Type of funding source: None

Characterization and clinical implications of peripheral arterial involvement in transthyretin cardiac amyloidosis cardiomyopathy

Background

The sporadic form of transthyretin amyloidosis cardiomyopathy (ATTR-CM) is underdiagnosed but its prevalence is increasing due to the aging population. Given the poor prognosis of ATTR-CM understanding the underlying pathophysiologic mechanisms of the disease is imperative in order to improve strategies for early diagnosis and risk stratification and to develop new effective therapeutic options. ATTR-CM is associated with hypotension and there is preliminary experimental evidence of vascular involvement but its presence and clinical significance remains unknown.

Purpose

To characterize peripheral arterial involvement and explore its clinical role in ATTR-CM.

Methods

We consecutively recruited 28 previously untreated patients with newly diagnosed ATTR-CM and 34 elderly controls &gt;70 years old, without ATTR-CM or heart failure. In both groups, flow-mediated dilatation (FMD) and intima-media thickness (IMT) in the carotid arteries were measured by high-resolution ultrasonography as markers of peripheral vascular reactivity and of subclinical atherosclerosis, respectively. Carotid-femoral pulse wave velocity (PWV) was measured as a marker of arterial stiffness. Aortic blood pressure (BP) and augmentation index (AI) using applanation tonometry were measured as markers of arterial wave reflections, peripheral arterial resistance and central hemodynamics. Echocardiography was performed in all ATTR patients. All cardiovascular (CV) measurements were performed before administration of any ATTR-specific therapy.

Results

ATTR patients were older and had lower prevalence of hypertension and male gender (p&lt;0.05 for all) than the control group. Aortic and peripheral BP (p=0.016–0.088) and AI (p=0.003) were lower in ATTR patients. IMT in the common (cc) and internal carotid (ic) as well as in the carotid bulb (cb) were significantly higher in ATTR patients (p=0.001–0.042). After multivariable adjustment for traditional CV disease (CVD) risk factors, the ATTR group was independently associated with AI and IMT in cc, cb and ic (p&lt;0.05 for all). In a subgroup of subjects with similar age between groups (n=13 and n=33 and 74.5±2.9 vs. 75.6±3.6 years, for ATTR vs. controls, respectively) differences in AI and cbIMT remained significant. Interestingly, AI was strongly and inversely associated with interventricular wall thickness (IVwt) in ATTR patients (spearman rho=−0.651, p=0.001). After adjustment for traditional CVD risk factors this association remained significant.

Conclusion

ATTR-CM is associated with lower aortic wave reflections, which correlate with more advanced structural cardiac disease, as assessed by IVwt. Further, ATTR-CM patients present accelerated subclinical carotid atherosclerosis as compared to elderly control subjects. These findings suggest that in ATTR-CM there is disease-specific peripheral vascular involvement in parallel to cardiac involvement. The clinical significance of these findings merits further investigation.

Funding Acknowledgement

Type of funding source: None

Investigating the impact of aging and hyperlipidaemia on metformin cardioprotection against carfilzomib-induced cardiotoxicity in vivo

Background

Carfilzomib (Cfz) is an irreversible proteasome inhibitor, indicated for the treatment of Multiple Myeloma (MM); however, is associated with cardiotoxicity in humans. Metformin (Met) has been suggested as a prophylactic therapy against Cfz-induced cardiotoxicity in mice.

Purpose

Considering that MM is an elderly disease, manifested in presence of cardiovascular comorbidities, we investigated the cardioprotective effect of Met against Cfz-cardiomyopathy on the age- or hyperlipidaemia-burdened myocardium in vivo.

Methods

Aging model: Male C57BL/6 mice, 15-month old, were randomized into: 1. Control (N/S 0.9%), 2. Met (140 mg/kg, po), 3. Cfz (8mg/kg, ip) and 4. Cfz+Met (8 and 140 mg/kg respectively) (n=5–7/group). Hyperlipidaemic model: ApoE−/− male mice, 20-weeks old were randomized into: 1. Control (N/S 0.9%), 2. Met (140 mg/kg, po), 3. Cfz (8mg/kg, ip) and 4. Cfz+Met (8 and 140 mg/kg respectively) (n=6/group). Cfz was administered every 48 hours and Met every 24 hours for 6 days. At baseline and at the end of treatments mice underwent echocardiography. Proteasomal activity and molecular signaling mechanisms were assessed in myocardial tissue and in peripheral blood mononuclear cells (PBMCs).

Results

Aging model: Proteasome activity was significantly reduced in myocardial tissue of aged vs young mice (P&lt;0.05). Cfz-treated mice showed an additional decrease in proteasomal activity compared to Control (P&lt;0.05) and Met (P&lt;0.01) groups, in heart and PBMCs. A significant fractional shortening (FS%) reduction was observed in Cfz group vs controls at day 6 (29.90±1.7 vs 37.60±0.2, respectively, P&lt;0.05) while Met in both Met and Cfz+Met groups maintained FS% vs controls (34.88±1.6, 33.20±0.6 vs 37.60±0.2, respectively, P=NS). By investigating molecular signaling pathways involved in cardioprotection, we observed that Cfz led to a decrease of Akt and AMPKα phosphorylation (P&lt;0.05 vs Control), whereas Cfz+Met co-administration restored Akt and AMPKα phosphorylation and upregulated t-eNOS and t-Akt (P&lt;0.05 vs Control). Hyperlipidaemic model: In ApoE−/− mice, no significant reduction of myocardial proteasomal activity was observed, whilst PBMCs proteasomal activity was decreased compared to controls (P&lt;0.05). Cfz treated ApoE−/− mice exhibited a reduction of myocardial (P&lt;0.01 in Cfz and P&lt;0.001 in Cfz+Met) and PBMCs' proteasome activity (P&lt;0.001) vs controls. Interestingly, Cfz, Met as well as the combination led to a decrease in FS% versus controls (44.00±1.2, 42.33±0.92, 42.33±1.0 vs 47.50±0.72 respectively, P&lt;0.05).

Conclusions

Our results demonstrate that Met retains its prophylactic potency against Cfz-induced cardiotoxicity in aged mice and activates cardioprotective signaling molecules. In the ApoE−/− mice, Met failed to exert cardioprotection against Cfz induced cardiomyopathy. Therefore, the monitoring of the cardiovascular burden seems to be of outmost importance in managing Cfz cardiac adverse effects.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Amgen

A proposed index of diffuse bone marrow [18F]-FDG uptake and PET skeletal patterns correlate with myeloma prognostic markers, plasma cell morphology, and response to therapy

PURPOSE

The investigation of a semi-quantitative index in the pelvis to assess for diffuse bone marrow (BM) [18F]-FDG uptake and the investigation of PET skeletal patterns in multiple myeloma (MM) patients, in accordance with prognostic markers, clonal plasma cell (cPC) morphology, and response to therapy.

METHODS

We prospectively analyzed [18F]-FDG PET/CT in 90 MM patients (newly diagnosed, 60; relapsed/refractory, 30). Among other PET/CT parameters, we calculated the ratio SUVmax pelvis/liver and examined for correlations with known MM prognostic parameters, cPC morphology (good vs. low/intermediate differentiation), and response to therapy.

RESULTS

SUVmax pelvis/liver ratio was significantly lower for the group of good differentiation vs. intermediate/low differentiation cPCs (p < 0.001) and showed a positive correlation with BM infiltration rate, β2 microglobulin, serum ferritin, international staging system (ISS), and revised ISS; no significant correlation was found with hemoglobin. A cutoff value of 1.1 showed an excellent specificity (99%) and high sensitivity (76%) for diffuse BM involvement (AUC 0.94; p < 0.001). Mixed pattern and appendicular involvement correlated with poor prognostic features while normal pattern, found in 30% of patients, correlated with good prognostic features. Presence of ≥ 10 focal lesions negatively predicted for overall response (p < 0.05; OR 4.8). The CT component improved the diagnostic performance of PET.

CONCLUSION

This study showed, for the first time, that cPC morphology and markers related with MM biology, correlate with SUVmax pelvis/liver index, which could be used as a surrogate marker for BM assessment and disease prognosis; PET patterns correlate with MM prognostic features and response rates.

Prevention, monitoring and treatment of cardiovascular adverse events in myeloma patients receiving carfilzomib A consensus paper by the European Myeloma Network and the Italian Society of Arterial Hypertension

BACKGROUND

The novel proteasome inhibitor carfilzomib alone or in combination with other agents is already one of the standard therapies for relapsed and/or refractory multiple myeloma (MM) patients and produces impressive response rates in newly diagnosed MM as well. However, carfilzomib-related cardiovascular adverse events (CVAEs) - including hypertension (all grades: 12.2%; grade ≥3: 4.3%), heart failure (all grades: 4.1%; grade ≥3: 2.5%) and ischemic heart disease (all grades: 1.8%; grade ≥3: 0.8%) - may lead to treatment suspensions. At present, there are neither prospective studies nor expert consensus on the prevention, monitoring and treatment of CVAEs in myeloma patients treated with carfilzomib.

METHODS

An expert panel of the European Myeloma Network in collaboration with the Italian Society of Arterial Hypertension and with the endorsement of the European Hematology Association aimed to provide recommendations to support health professionals in selecting the best management strategies for patients, considering the impact on outcome and the risk-benefit ratio of diagnostic and therapeutic tools, thereby achieving myeloma response with novel combination approaches whilst preventing CVAEs.

RESULTS

Patients scheduled to receive carfilzomib need a careful cardiovascular evaluation before treatment and an accurate follow-up during treatment.

CONCLUSIONS

A detailed clinical assessment before starting carfilzomib treatment is essential to identify patients at risk for CVAEs, and accurate monitoring of blood pressure and of early signs and symptoms suggestive of cardiac dysfunction remains pivotal to safely administer carfilzomib without treatment interruptions or dose reductions.

Diagnosis, treatment, and response assessment in solitary plasmacytoma: updated recommendations from a European Expert Panel

Solitary plasmacytoma is an infrequent form of plasma cell dyscrasia that presents as a single mass of monoclonal plasma cells, located either extramedullary or intraosseous. In some patients, a bone marrow aspiration can detect a low monoclonal plasma cell infiltration which indicates a high risk of early progression to an overt myeloma disease. Before treatment initiation, whole body positron emission tomography-computed tomography or magnetic resonance imaging should be performed to exclude the presence of additional malignant lesions. For decades, treatment has been based on high-dose radiation, but studies exploring the potential benefit of systemic therapies for high-risk patients are urgently needed. In this review, a panel of expert European hematologists updates the recommendations on the diagnosis and management of patients with solitary plasmacytoma.

Prevention and management of adverse events of Novel agents in multiple myeloma: A consensus of the european myeloma network

During the last few years, several new drugs have been introduced for treatment of patients with multiple myeloma, which have significantly improved treatment outcome. All of these novel substances differ at least in part in their mode of action from similar drugs of the same drug class, or are representatives of new drugs classes, and as such present with very specific side effect profiles. In this review, we summarize these adverse events, provide information on their prevention, and give practical guidance for monitoring of patients and for management of adverse events.Leukemia accepted article preview online, 18 December 2017. doi:10.1038/leu.2017.353.

The role of sclerostin/dickkopf-1 and receptor activator of nuclear factor kB ligand/osteoprotegerin signalling pathways in the development of osteoporosis in patients with haemophilia A and B: A cross-sectional study

AIM

Haemophilia A and B are associated with reduced bone mineral density (BMD). The aim of this study was to assess circulating sclerostin and dickkopf-1 (Dkk-1), (inhibitors of osteoblastic differentiation), as well as the receptor activator of nuclear factor kB ligand (RANKL)/osteoprotegerin (OPG) system (the major regulator of osteoclastogenesis), in patients with haemophilia (PWH), their possible correlations with clinical risk factors and the effect of ibandronate on these markers.

METHODS

Eighty-nine male PWH (mean age 45.9 ± 15.3 years) and 30 age-matched healthy male controls participated. BMD was assessed by DXA. Sclerostin, Dkk-1, RANKL and OPG were measured in serum of patients, controls, as well as in ten patients receiving oral ibandronate (150 mg/mo), at baseline and after 12 months.

RESULTS

Patients with haemophilia had lower circulating sclerostin (median ± IQR: 47.4 ± 26.93 vs 250 ± 250 pmol/L, P < .001), Dkk-1 (21.24 ± 17.18 vs 26.16 ± 15.32pg/mL, P = .04) and higher levels of RANKL (0.23 ± 0.03 vs 0.04 ± 0.03 pmol/L, P = .001), RANKL/OPG ratio (0.063 ± 0.25 vs 0.005 ± 0.11, P = .001) compared with controls. Patients with low BMD had higher OPG concentrations compared to those with normal BMD. Sclerostin and RANKL/OPG correlated positively with BMD. Patients with severe haemophilia had lower sclerostin concentrations compared with those with mild or moderate disease. The degree of arthropathy negatively correlated with sclerostin and Dkk-1 levels. PWH who received ibandronate showed a decrease in serum Dkk-1 without any significant effect on sclerostin and RANKL/OPG.

CONCLUSIONS

Patients with haemophilia present increased osteoclastic activity coupled with compensatory increased osteoblastic activity. Ibandronate did not affect RANKL/OPG ratio, but it decreased Dkk-1.

Mechanisms of bone destruction in multiple myeloma

Osteolytic bone disease is a frequent complication of multiple myeloma, resulting in skeletal complications that are a significant cause of morbidity and mortality. It is the result of an increased activity of osteoclasts, which is not followed by reactive bone formation by osteoblasts. Recent studies have revealed novel molecules and pathways that are implicated in osteoclast activation and osteoblast inhibition. Among them, the most important include the receptor activator of nuclear factor-kappa B ligand/osteoprotegerin pathway, the macrophage inflammatory proteins and the activin-A that play a crucial role in osteoclast stimulation in myeloma, while the wingless-type (Wnt) signalling inhibitors (sclerostin and dickkopf-1) along with the growth factor independence-1 are considered the most important factors for the osteoblast dysfunction of myeloma patients. Finally, the role of osteocytes, which is the key cell for normal bone remodelling, has also revealed during the last years through their interaction with myeloma cells that leads to their apoptosis and the release of RANKL and sclerostin maintaining bone loss in these patients. This review focuses on the latest available data for the mechanisms of bone destruction in multiple myeloma.

Addition of cyclophosphamide and higher doses of dexamethasone do not improve outcomes of patients with AL amyloidosis treated with bortezomib

Bortezomib, in combination with dexamethasone (VD) or with the addition of cyclophosphamide (VCD), is highly effective in patients with amyloid light-chain (AL) amyloidosis. Currently, VCD is considered as a primary regimen for patients with AL, but it is not clear whether the addition of cyclophosphamide to VD further and significantly improves efficacy, given the substantial activity of bortezomib itself. We retrospectively compared the outcomes of 101 patients with AL amyloidosis who received VD (n=59) or VCD (n=42) in two consecutive periods. Early mortality after adjustment for Mayo stage was similar. On intent to treat, a hematologic response rate was 68% for patients treated with VD and 78% for VCD (P=0.26), while complete response+very good partial response (CR+VGPR) rate was 47.5% and 35%, respectively. Higher doses of dexamethasone or twice-weekly bortezomib were not associated with significantly higher CR+VGPR rates. Organ responses occurred in similar rates between the two groups. Median survival was similar (33 vs 36 months, P=0.45) even after adjustment for Mayo stage and dose and schedule of bortezomib and dexamethasone. In conclusion, bortezomib even with low doses of dexamethasone is effective for the treatment of AL amyloidosis; higher doses of dexamethasone and addition of cyclophosphamide do not seem to have a profound effect on efficacy and survival.

Fetal Erythropoiesis after Allogeneic Bone Marrow Transplantation Estimated by the Peripheral Blood Erythrocytes Containing Hemoglobin F (F-cells)

During bone marrow engraftment following BMT there is a re-establishment of fetal erythropoiesis, expressed by the increase of F-cells. This seems to depend on several factors such as underlying disease, conditioning before therapy and other mechanisms concerning both the donor and the recipient bone marrow. The aim of this work was to study the factors influencing F-cell production during bone marrow engraftment following transplantation. We studied 28 patients who underwent allogeneic bone marrow transplantation, for various hematological malignancies (CML, AML, ALL, CMML and SAA). F-cells were estimated on peripheral blood smears by indirect immunofluorescence. Overall, there was an F-cell increase after BMT in comparison with values before BMT; this increase was significant on days 15-50 (p <.01). F-cell on days 18, 25, 32 and 40 following transplantation were significantly higher (p <.01) in patients who have had increased F-cell numbers post-chemotherapy before BMT, compared with the patients who did not show any increase of the F-cell number post chemotherapy. During the first month following transplantation (day 7 to day 40) patients who were transplanted from high F-cell donors failed to show any significant differences in their F-cell numbers in comparison to those transplanted from low F-cell donors. However, the F-cell increase became significantly higher in the former group between days 50 and 120. This observation implies that the stressed erythropoiesis of the initial phase does not allow revealing the varying F-cell production of the capacities donor bone marrow, while later, when the graft has settled, the high F-cell donors reveal this property of the host.

The Development of an Angiogenic Protein "Signature" in Ovarian Cancer Ascites as a Tool for Biologic and Prognostic Profiling

Advanced ovarian cancer (AOC) is one of the leading lethal gynecological cancers in developed countries. Based on the important role of angiogenesis in ovarian cancer oncogenesis and expansion, we hypothesized that the development of an "angiogenic signature" might be helpful in prediction of prognosis and efficacy of anti-angiogenic therapies in this disease. Sixty-nine samples of ascitic fluid- 35 from platinum sensitive and 34 from platinum resistant patients managed with cytoreductive surgery and 1st-line carboplatin-based chemotherapy- were analyzed using the Proteome ProfilerTM Human Angiogenesis Array Kit, screening for the presence of 55 soluble angiogenesis-related factors. A protein profile based on the expression of a subset of 25 factors could accurately separate resistant from sensitive patients with a success rate of approximately 90%. The protein profile corresponding to the "sensitive" subset was associated with significantly longer PFS (8 [95% Confidence Interval {CI}: 8-9] vs. 20 months [95% CI: 15-28]; Hazard ratio {HR}: 8.3, p<0.001) and OS (20.5 months [95% CI: 13.5-30] vs. 74 months [95% CI: 36-not reached]; HR: 5.6 [95% CI: 2.8-11.2]; p<0.001). This prognostic performance was superior to that of stage, histology and residual disease after cytoreductive surgery and the levels of vascular endothelial growth factor (VEGF) in ascites. In conclusion, we developed an "angiogenic signature" for patients with AOC, which can be used, after appropriate validation, as a prognostic marker and a tool for selection for anti-angiogenic therapies.

Cost of skeletal complications from bone metastases in six European countries

Objective Patients with bone metastases or lesions secondary to solid tumors or multiple myeloma often experience bone complications (skeletal-related events [SREs]-radiation to bone, pathologic fracture, surgery to bone, and spinal cord compression); however, recent data that can be used to assess the value of treatments to prevent SREs across European countries are limited. This study aimed to provide estimates of health resource utilization (HRU) and cost associated with all SRE types in Europe. HRU data were reported previously; cost data are reported herein. Methods Eligible patients from 49 centers across Austria (n = 57), the Czech Republic (n = 59), Finland (n = 60), Greece (n = 59), Portugal (n = 59), and Sweden (n = 62) had bone metastases or lesions secondary to breast, lung, or prostate cancer, or multiple myeloma, and ≥1 index SRE (a SRE preceded by a SRE-free period of ≥ 6.5 months). SRE-related costs were estimated from a payer perspective using health resource utilization data from patient charts (before and after the index SRE diagnosis). Country-specific unit costs were from 2010 and local currencies were converted to 2010 euros. Results The mean costs across countries were €7043, €5242, €11,101, and €11,509 per radiation to bone, pathologic fracture, surgery to bone, and spinal cord compression event, respectively. Purchasing power parity (PPP)-adjusted mean cost ratios were similar in most countries, with the exception of radiation to bone. Limitations The overall burden of SREs may have been under-estimated owing to home visits and evaluations outside the hospital setting not being reported here. Conclusions All SREs were associated with substantial costs. Variation in SRE-associated costs between countries was most likely driven by differences in treatment practices and unit costs.

Baseline osteocalcin levels and incident diabetes in a 3-year prospective study of high-risk individuals

AIM

Experimental evidence suggests that osteocalcin is a key messenger that affects both adipocytes and insulin-producing β cells. Epidemiological cross-sectional studies have shown a negative association between plasma levels of osteocalcin and glucose. For this reason, the hypothesis that lower baseline osteocalcin plasma levels are associated with diabetes was prospectively tested.

METHODS

The study population consisted of individuals at high risk for type 2 diabetes who were screened for participation in the Greek arm of a European type 2 diabetes prevention study (the DE-PLAN study). All participants were free of diabetes at baseline and underwent a second evaluation 3 years later. Diabetes status was defined according to an oral glucose tolerance test.

RESULTS

A total of 307 subjects were included in the present analysis. The population, including 154 men (50.3%), was middle-aged (54.4 ± 10.2 years) and overweight (BMI: 29.5 ± 4.9 kg/m(2)). At baseline, mean total plasma osteocalcin was lower in those with impaired fasting glucose and/or impaired glucose tolerance compared with those with normal glucose tolerance (6.0 ± 3.1 ng/mL vs. 7.3 ± 4.0 ng/mL, respectively; P = 0.01). After 3 years, 36 subjects had developed diabetes. In the prospective evaluation, there was no association between baseline osteocalcin levels and diabetes (OR: 1.04 per 1 ng/mL, 95% CI: 0.93-1.15; P = 0.49) on multivariable logistic regression analysis, nor was there any correlation with changes in plasma glucose after 3 years (r = 0.09, P = 0.38).

CONCLUSION

Our prospective results show that lower levels of circulating osteocalcin do not predict future diabetes development and, in contrast to most cross-sectional published data so far, suggest that this molecule may not be playing a major role in glucose homoeostasis in humans.

Circulating periostin levels do not differ between postmenopausal women with normal and low bone mass and are not affected by zoledronic acid treatment

Periostin is a secreted extracellular matrix protein preferentially expressed in bone by osteocytes and periosteal osteoblasts. Reduced periostin expression may affect osteoblast differentiation and collagen type I synthesis and predispose to osteoporosis and increased fracture risk. We aimed to evaluate circulating periostin levels in postmenopausal women with low bone mass, their possible correlations with clinical and laboratory parameters, as well as the 3-month effect of zoledronic acid. Serum samples for periostin, 25-hydroxyvitamin D, parathyroid hormone (PTH), C-terminal telopeptide of type I collagen (CTx), and total alkaline phosphatase (tALP) were obtained from 46 postmenopausal women with low bone mass at baseline and 3 months after zoledronic acid infusion and from 30 age-matched, postmenopausal controls with normal bone mass at baseline. There was no difference in periostin levels between women with normal and low bone mass (250±15 vs. 272±14 ng/ml, respectively; p=0.279). Periostin remained essentially unchanged after zoledronic acid infusion (262±18 ng/ml; p=0.130). Serum periostin levels at baseline were not affected by previous bisphosphonate treatment, and were correlated only to tALP (rs=0.351; p=0.018). In multiple linear regression analysis, tALP (B=3.17; 95% CI=0.59-5.79; p=0.018) was associated with serum periostin levels at baseline, independently from previous anti-osteoporotic treatment, age, body mass index, and 25-hydroxyvitamin D. In conclusion, serum periostin levels do not differ between postmenopausal women with normal and low bone mass and are not affected by zoledronic acid treatment. Women with higher tALP have independently higher periostin levels.