1
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Alnasser SM, Alharbi KS, Almutairy AF, Almutairi SM, Alolayan AM. Autologous Stem Cell Transplant in Hodgkin's and Non-Hodgkin's Lymphoma, Multiple Myeloma, and AL Amyloidosis. Cells 2023; 12:2855. [PMID: 38132175 PMCID: PMC10741865 DOI: 10.3390/cells12242855] [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: 11/12/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Human body cells are stem cell (SC) derivatives originating from bone marrow. Their special characteristics include their capacity to support the formation and self-repair of the cells. Cancer cells multiply uncontrollably and invade healthy tissues, making stem cell transplants a viable option for cancer patients undergoing high-dose chemotherapy (HDC). When chemotherapy is used at very high doses to eradicate all cancer cells from aggressive tumors, blood-forming cells and leukocytes are either completely or partially destroyed. Autologous stem cell transplantation (ASCT) is necessary for patients in those circumstances. The patients who undergo autologous transplants receive their own stem cells (SCs). The transplanted stem cells first come into contact with the bone marrow and then undergo engraftment, before differentiating into blood cells. ASCT is one of the most significant and innovative strategies for treating diseases. Here we focus on the treatment of Hodgkin's lymphoma, non-Hodgkin's lymphoma, multiple myeloma, and AL amyloidosis, using ASCT. This review provides a comprehensive picture of the effectiveness and the safety of ASCT as a therapeutic approach for these diseases, based on the currently available evidence.
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Affiliation(s)
- Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Khalid Saad Alharbi
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Ali F. Almutairy
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
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2
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Iijima T, Sawa N, Nakayama Y, Oba Y, Ikuma D, Mizuno H, Yamanouchi M, Suwabe T, Wake A, Kono K, Hoshino J, Ubara Y, Ohashi K. Vincristine, Doxorubicin, and Dexamethasone Induction before Autologous Stem Cell Transplantation in Patients with AL Amyloidosis: A Retrospective Comparison with Frontline Stem Cell Transplantation. Intern Med 2022; 61:2853-2860. [PMID: 35228429 PMCID: PMC9593158 DOI: 10.2169/internalmedicine.9039-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective High-dose melphalan and autologous stem cell transplantation (ASCT) therapy for AL amyloidosis are now associated with reduced mortality based on the application of strict criteria. However, there is no long-term evidence concerning the performance of induction therapy with newer agents, such as bortezomib or daratumumab. Concerns regarding long-term relapse despite treatment with ASCT exist, and missing the opportunity to perform ASCT might occur if induction proves to not be efficacious and cardiac amyloidosis progression deprives the patients of a chance to receive ASCT. We herein report good amyloid control by vincristine, doxorubicin, and dexamethasone (VAD) induction therapy and argue the importance of induction therapy before ASCT. Methods We compared patients who underwent VAD induction and ASCT (VAD+ASCT) with patients who underwent frontline ASCT in our hospital. Patients A total of 26 patients with histologically proven AL amyloidosis were included (18 in the VAD+ASCT group and 8 in the frontline ASCT). Results In the VAD+ASCT group, the 10-year overall survival and renal response rates were 82% and 43%, respectively. The renal response rate at two years in the VAD+ASCT group was significantly better than that in the frontline ASCT group. Although there was no significant difference in the survival rates between the two groups, the time to next treatment or death was significantly better in the VAD+ASCT group than in the the frontline ASCT group. Acute kidney injury was the most frequent reason for failure to receive two courses of VAD, and early mortality was mainly due to gastrointestinal complications. Conclusion Considering that only those who underwent 2 courses of VAD experienced a 10-year renal response, induction therapy was deemed to be directly related to the long-term control of AL amyloidosis.
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Affiliation(s)
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yuki Nakayama
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
| | - Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Atsushi Wake
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
- Department of Hematology, Toranomon Hospital Kajigaya, Japan
- Department of Hematology, Toranomon Hospital, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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3
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Gustine JN, Staron A, Szalat R, Mendelson L, Joshi T, Ruberg FL, Siddiqi O, Gopal DM, Edwards CV, Havasi A, Kaku M, Lau KHV, Berk JL, Sloan JM, Sanchorawala V. Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: a 25-year longitudinal study. Am J Hematol 2022; 97:1189-1199. [PMID: 35731907 DOI: 10.1002/ajh.26641] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/07/2022]
Abstract
High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I >0.1 ng/mL, and serum creatinine >2.0 mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p<0.001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joshua N Gustine
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Raphael Szalat
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Omar Siddiqi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Deepa M Gopal
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Camille V Edwards
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Michelle Kaku
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - K H Vincent Lau
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Pulmonology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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4
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Kumar S, Li D, Joseph D, Trachtenberg B. State-of-the-art review on management of end-stage heart failure in amyloidosis: transplant and beyond. Heart Fail Rev 2022; 27:1567-1578. [PMID: 35112265 DOI: 10.1007/s10741-021-10209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/04/2022]
Abstract
Cardiac involvement occurs in light-chain (AL), transthyretin wild-type (wtATTR), and hereditary (hATTR) amyloidosis; other types of amyloidosis account for < 5% of all cardiac amyloidosis (CA). CA can present subclinically on screening, insidiously with symptoms such as exertional dyspnea, or abruptly as cardiogenic shock. Initially, CA patients were thought to be poor candidates for transplant due to short long-term survival; however, there is a marked improvement in heart and multi-organ transplant outcomes over the past 10 years with newer treatments and improvements in support with temporary and durable mechanical circulatory support while awaiting transplant. Patients with AL CA were reported to have worse post-OHT outcomes than patients with ATTR CA, but this gap is quickly closing with improved patient selection, novel chemotherapeutics, and perhaps with selected use of bone marrow transplantation. Waitlist mortality and transplantation rates have markedly improved for CA after the United Network for Organ Sharing (UNOS) policy change in October 2018. In this review, we will evaluate contemporary data from the last 5 years on advances in the field of transplantation and mechanical circulatory support in this patient population.
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Affiliation(s)
- Salil Kumar
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Daniel Li
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Denny Joseph
- Department of Internal Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Barry Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA. .,Houston Methodist J.C. Walter Jr. Transplant Center, Houston, TX, USA.
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5
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Varga C. Autologous Stem Cell Transplantation in Light Chain Amyloidosis: The Ultimate Treatment? Transplant Cell Ther 2022; 28:57-58. [DOI: 10.1016/j.jtct.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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6
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Othus M, Zhang MJ, Gale RP. Clinical trials: design, endpoints and interpretation of outcomes. Bone Marrow Transplant 2022; 57:338-342. [PMID: 34997213 DOI: 10.1038/s41409-021-01542-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 11/12/2022]
Affiliation(s)
- Megan Othus
- Division of Public Health, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
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7
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Abstract
Cardiac amyloidosis, a form of infiltrative cardiomyopathy, is associated with poor prognosis in untreated patients. Early diagnosis is important for timely initiation of effective therapies. Despite advances in diagnostic modalities, it remains a challenging diagnosis, requiring high index of clinical suspicion. Echocardiography represents the first-line cardiac imaging modality for evaluation of heart failure and suspected cardiac amyloidosis. In this review, we discuss echocardiographic findings in cardiac amyloidosis.
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8
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Elsayed M, Usher S, Habib MH, Ahmed N, Ali J, Begemann M, Shabbir SA, Shune L, Al-Hilli J, Cossor F, Sperry BW, Raza S. Current Updates on the Management of AL Amyloidosis. J Hematol 2021; 10:147-161. [PMID: 34527111 PMCID: PMC8425803 DOI: 10.14740/jh866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 12/17/2022] Open
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is a rare but fatal disease. It results from clonal proliferation of plasma cells with excessive production of insoluble misfolded proteins that aggregate in the extracellular matrix, causing damage to the normal architecture and function of various organs. For decades, treatment for AL amyloidosis was based mainly on therapeutic agents previously studied for its more common counterpart, multiple myeloma. As the prevalence and incidence of AL amyloidosis have increased, ongoing research has been conducted with treatments typically used in myeloma with varying success. In this review, we focus on current treatment strategies and updates to clinical guidelines and therapeutics for AL amyloidosis.
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Affiliation(s)
- Marwa Elsayed
- St Luke’s Hospital of Kansas City, University of Missouri Kansas City, Wornall Rd, Kansas City, MO 64111, USA
| | - Sara Usher
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | - Muhammad Hamza Habib
- Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA
| | - Nausheen Ahmed
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jawad Ali
- West Midland Deanery, 213 Hagley Road, Birmingham, B16 9RG, UK
| | - Madeline Begemann
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | | | - Leila Shune
- University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA
| | - Jaffar Al-Hilli
- University of Missouri Columbia, 1 Hospital Dr, Columbia, MO 65212, USA
| | - Furha Cossor
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
| | - Brett W. Sperry
- Mid America Heart Institute, St Luke’s Hospital of Kansas City, Wornall Rd, Kansas City, MO 64111, USA
| | - Shahzad Raza
- St Luke’s Cancer Institute, University of Missouri Kansas City, 4321 Washington St, Ste 4000, Kansas City, MO 64111, USA
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9
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Huang X, Ren G, Chen W, Guo J, Zhao L, Zeng C, Ge Y, Liu Z. The role of induction therapy before autologous stem cell transplantation in low disease burden AL amyloidosis patients. Amyloid 2021; 28:75-83. [PMID: 33084412 DOI: 10.1080/13506129.2020.1835635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Induction therapy is recommended before autologous stem cell transplantation (ASCT) for AL amyloidosis patients with high disease burden [bone marrow plasma cells (BMPCs) > 10%], but the role of induction therapy before ASCT in patients with low disease burden (BMPCs ≤ 10%) is still unknown. METHODS A total of 227 patients with AL amyloidosis were included in this study. Among 227 patients, 124 patients received bortezomib-based induction prior to ASCT and were defined as group A, 35 patients received other chemotherapeutic induction and were defined as group B, and the other 68 patients without induction were defined as group C. We compared the differences of efficacy and prognosis between the three groups. RESULTS The haematological overall response rates (ORR) of groups A, B and C were 91%, 67% and 75%, respectively. The complete response rates (CR) of groups A, B and C were 50%, 25% and 20%, respectively. Both the ORR and CR rates of group A were significantly higher than those of groups B and C. The renal response rates of groups A, B and C were 64%, 46% and 47%, respectively. The cardiac response rates of groups A, B and C were 74%, 45% and 40%, respectively. The renal and cardiac responses rates of group A were also significantly higher than those of the other two groups. After a median follow-up of 44 months, the median OS was not reached. The 5-year estimated overall survival (OS) rates of groups A, B and C were 81%, 57% and 67%, respectively. The median progression-free survival (PFS) was 83 months for all patients. The 5-year estimated PFS rates of groups A, B and C were 61%, 38% and 49%, respectively. Both the OS and PFS of group A were higher than those of both group B and group C. On multivariate analysis, baseline dFLC > 50 mg/L was associated with worse survival, but induction with bortezomib was associated with better survival. CONCLUSION Our study demonstrated that low disease burden AL patients who are eligible for ASCT may benefit from bortezomib-based induction therapy.
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Affiliation(s)
- Xianghua Huang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Guisheng Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wencui Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jinzhou Guo
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Liang Zhao
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yongchun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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10
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Vaxman I, Sidiqi MH, Al Saleh AS, Kumar S, Muchtar E, Dispenzieri A, Buadi F, Dingli D, Lacy M, Hayman S, Leung N, Gonsalves W, Kourelis T, Warsame R, Hogan W, Gertz M. Depth of response prior to autologous stem cell transplantation predicts survival in light chain amyloidosis. Bone Marrow Transplant 2020; 56:928-935. [PMID: 33208916 DOI: 10.1038/s41409-020-01136-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/25/2020] [Accepted: 11/03/2020] [Indexed: 12/16/2022]
Abstract
The goal of therapy in AL amyloidosis is to inhibit further production of the amyloidogenic light chains, thereby allowing organ recovery and improving survival. We aimed to assess the impact of depth of hematologic response prior to ASCT on survival. We conducted a retrospective study of 128 newly diagnosed AL amyloidosis patients who received induction prior to ASCT between January 2007 and August 2017 at Mayo Clinic. The overall response rate to induction was 86% (CR 18%, VGPR 31% and PR 38%). With a median follow up of 52 months, the median PFS and OS was 48.5 months and not reached, respectively. Response depth to induction therapy was associated with improved PFS and OS. The median PFS was not reached for patients achieving ≥VGPR prior to ASCT and 34.1 months for patients achieving PR or less (P = 0.0009). The median OS was longer in patients with deeper responses (not reached for ≥VGPR vs. 128 months for PR or less (P = 0.02)). On multivariable analysis, independent predictors of OS were melphalan conditioning dose (RR = 0.42; P = 0.036) and depth of response prior to transplant (RR 0.37; P = 0.0295). Hematologic response prior to transplant predicts improved post transplant outcomes in AL amyloidosis.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel.,Israel Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | - M Hasib Sidiqi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Fiona Stanley Hospital, Perth, WA, Australia
| | - Abdullah S Al Saleh
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shaji Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Francis Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Martha Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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11
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Trachtenberg BH, Kamble R, Bhimaraj A, Estep JD. Should We Be for ASCT?: If Yes, Then When? JACC-HEART FAILURE 2020; 8:695-696. [PMID: 32731949 DOI: 10.1016/j.jchf.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 11/15/2022]
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12
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Sanchorawala V. High-Dose Melphalan and Autologous Peripheral Blood Stem Cell Transplantation in AL Amyloidosis. Acta Haematol 2020; 143:381-387. [PMID: 32248194 DOI: 10.1159/000506498] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 12/17/2022]
Abstract
AL amyloidosis is a systemic amyloidosis and is associated with an underlying plasma cell dyscrasia. High-dose intravenous melphalan and autologous stem cell transplantation was developed for the treatment of AL amyloidosis in the early 1990s and was prompted by its success in myeloma. This application has evolved significantly over the past three decades. This review provides a comprehensive assessment of eligibility criteria, stem cell collection, and mobilization strategies and regimens, risk-adapted melphalan dosing, role for induction and consolidation therapies as well as long-term outcome with respect to survival, hematologic response and relapse as well as organ responses following stem cell transplantation. Continued efforts to refine patient selection and management, and incorporate novel anti-plasma cell agents in combination or sequentially to further improve outcomes in AL amyloidosis are also discussed.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Stem Cell Transplantation Program of Section of Hematology and Oncology, Boston Medical Center, Boston, Massachusetts, USA,
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13
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Vaxman I, Dispenzieri A, Muchtar E, Gertz M. New developments in diagnosis, risk assessment and management in systemic amyloidosis. Blood Rev 2019; 40:100636. [PMID: 31706583 DOI: 10.1016/j.blre.2019.100636] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/19/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders characterized by a misfolded protein that deposits in organs and compromise their function. Clinician should have a high index of suspicion because in most cases, the clinical picture is non-specific. Typing of amyloid is of utmost importance and should be an integral part of accurately diagnosing a patient. AL amyloidosis is the most common systemic amyloidosis in the western world in which the misfolded proteins are immunoglobulin light chains secreted by clonal plasma cells. New data about prognostication of AL amyloidosis patients are accumulating. The treatment goal is to eradicate the amyloidogenic plasma cell clone, by using high dose melphalan and/or novel agents (proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies against CD38). Early diagnosis is important for effectively treating the patient as late diagnosis hampers chances for organ recovery. ATTR amyloidosis is less recognized but is increasingly seen due to better recognition and improved diagnostic tools. New data about treatment options (patisiran, inotersen and tafamidis) have recently been published and are discussed.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Israel Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | | | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Varga C, Comenzo RL. High-dose melphalan and stem cell transplantation in systemic AL amyloidosis in the era of novel anti-plasma cell therapy: a comprehensive review. Bone Marrow Transplant 2019; 54:508-518. [PMID: 30089901 DOI: 10.1038/s41409-018-0284-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 05/25/2018] [Accepted: 06/08/2018] [Indexed: 11/08/2022]
Abstract
The application of high-dose melphalan and autologous stem cell transplant (SCT) to systemic AL amyloidosis (AL) has evolved over the past two decades and remains an important component of therapy for patients with AL. The era of novel agents created the opportunity to provide well -tolerated induction and post-SCT consolidation to AL patients eligible for SCT and the current availability of new monoclonal antibody therapies will likely provide additional opportunities to enhance the outcomes with SCT. In this review, we touch on the history of SCT for AL and examine the data on eligibility, mobilization, induction, risk-adapted melphalan dosing, engraftment, consolidation and maintenance, and long-term outcomes with SCT. We note that induction therapy may deprive some patients of the opportunity to proceed to SCT but is likely needed if the marrow plasmacytosis is > 10%, that risk-adapted melphalan dosing continues to be relevant, and that post-SCT consolidation improves the complete response rate as well as long-term overall survival. The importance of baseline cytogenetics is also highlighted, particularly for patients whose clonal plasma cells are ≤ 10% but harbor the t(11;14), because they may have improved survival with SCT.
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Affiliation(s)
- Cindy Varga
- The Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA, USA.
- The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Raymond L Comenzo
- The Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA, USA
- The John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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Richey T, Foster JS, Williams AD, Williams AB, Stroh A, Macy S, Wooliver C, Heidel RE, Varanasi SK, Ergen EN, Trent DJ, Kania SA, Kennel SJ, Martin EB, Wall JS. Macrophage-Mediated Phagocytosis and Dissolution of Amyloid-Like Fibrils in Mice, Monitored by Optical Imaging. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:989-998. [PMID: 30735627 DOI: 10.1016/j.ajpath.2019.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/14/2019] [Accepted: 01/17/2019] [Indexed: 01/27/2023]
Abstract
Light chain-associated amyloidosis is characterized by the extracellular deposition of amyloid fibrils in abdominothoracic organs, skin, soft tissue, and peripheral nerves. Phagocytic cells of the innate immune system appear to be ineffective at clearing the material; however, human light chain amyloid extract, injected subcutaneously into mice, is rapidly cleared in a process that requires neutrophil activity. To better elucidate the phagocytosis of light chain fibrils, a potential method of cell-mediated dissolution, amyloid-like fibrils were labeled with the pH-sensitive dye pHrodo red and a near infrared fluorophore. After injecting this material subcutaneously in mice, optical imaging was used to quantitatively monitor phagocytosis and dissolution of fibrils concurrently. Histologic evaluation of the residual fibril masses revealed the presence of CD68+, F4/80+, ionized calcium binding adaptor molecule 1- macrophages containing Congo red-stained fibrils as well as neutrophil-associated proteins with no evidence of intact neutrophils. These data suggest an early infiltration of neutrophils, followed by extensive phagocytosis of the light chain fibrils by macrophages, leading to dissolution of the mass. Optical imaging of this novel murine model, coupled with histologic evaluation, can be used to study the cellular mechanisms underlying dissolution of synthetic amyloid-like fibrils and human amyloid extracts. In addition, it may serve as a test bed to evaluate investigational opsonizing agents that might serve as therapeutic agents for light chain-associated amyloidosis.
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Affiliation(s)
- Tina Richey
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - James S Foster
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Angela D Williams
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | | | - Alexa Stroh
- Department of Biochemistry, Cellular and Molecular Biology, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee
| | - Sallie Macy
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Craig Wooliver
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Siva K Varanasi
- Department of Biochemistry, Cellular and Molecular Biology, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee
| | - Elizabeth N Ergen
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Dianne J Trent
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee
| | - Stephen A Kania
- Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, Tennessee
| | - Stephen J Kennel
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Emily B Martin
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee
| | - Jonathan S Wall
- Department of Medicine, University of Tennessee Medical Center, Knoxville, Tennessee.
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Rutten KHG, Raymakers RAP, Hazenberg BPC, Nienhuis HLA, Vellenga E, Minnema MC. Haematological response and overall survival in two consecutive Dutch patient cohorts with AL amyloidosis diagnosed between 2008 and 2016. Amyloid 2018; 25:227-233. [PMID: 30513220 DOI: 10.1080/13506129.2018.1536043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although survival has improved in recent decades, the short-term prognosis of patients with immunoglobulin light chain (AL) amyloidosis remains grim. We aimed to assess overall survival (OS) of AL amyloidosis patients by comparing cohorts in two consecutive time periods. METHODS Data were collected and compared on 126 patients from two tertiary referral centres in The Netherlands during the time periods 2008-2012 and 2013-2016. RESULTS There was a non-significant trend to improved 6-month OS in the last cohort (78% vs. 67%, p = .216, crude odds ratio 1.66, 95%CI 0.74-3.70, adjusted odds ratio 2.22, 95%CI 0.88-5.56). Patients in this cohort had higher Mayo risk scores (stage III 40% vs. 24%, p < .001 and revised stage IV 14% vs. 11%, p < .001), higher use of bortezomib (50% vs. 30%), and better haematological response (complete response/very good partial response in 39% vs. 27%, p < .001). Diagnostic delay was similar in both time periods. CONCLUSIONS In the 2013-2016 cohort there was a trend toward improved 6-month OS, and an improved haematological response. Patients in this cohort had more advanced cardiac disease and received bortezomib more frequently, but diagnostic delay was similar to the 2008-2012 cohort. For further prognostic improvement, practitioners should be more alert, especially for cardiac amyloidosis.
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Affiliation(s)
- Karlijn H G Rutten
- a Department of Haematology , Utrecht University, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Reinier A P Raymakers
- a Department of Haematology , Utrecht University, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Bouke P C Hazenberg
- b Department of Rheumatology & Clinical Immunology , University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands
| | - Hans L A Nienhuis
- b Department of Rheumatology & Clinical Immunology , University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands
| | - Edo Vellenga
- c Department of Haematology , University of Groningen, University Medical Centre Groningen , Groningen , The Netherlands
| | - Monique C Minnema
- a Department of Haematology , Utrecht University, University Medical Centre Utrecht , Utrecht , The Netherlands
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Afrough A, Saliba RM, Hamdi A, Honhar M, Varma A, Cornelison AM, Rondon G, Parmar S, Shah ND, Bashir Q, Hosing C, Popat U, Weber DM, Thomas S, Orlowski RZ, Champlin RE, Qazilbash MH. Impact of Induction Therapy on the Outcome of Immunoglobulin Light Chain Amyloidosis after Autologous Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 24:2197-2203. [DOI: 10.1016/j.bbmt.2018.07.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/08/2018] [Indexed: 11/29/2022]
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Abstract
Systemic immunoglobulin light chain amyloidosis is a protein misfolding disease caused by the conversion of immunoglobulin light chains from their soluble functional states into highly organized amyloid fibrillar aggregates that lead to organ dysfunction. The disease is progressive and, accordingly, early diagnosis is vital to prevent irreversible organ damage, of which cardiac damage and renal damage predominate. The development of novel sensitive biomarkers and imaging technologies for the detection and quantification of organ involvement and damage is facilitating earlier diagnosis and improved evaluation of the efficacy of new and existing therapies. Treatment is guided by risk assessment, which is based on levels of cardiac biomarkers; close monitoring of clonal and organ responses guides duration of therapy and changes in regimen. Several new classes of drugs, such as proteasome inhibitors and immunomodulatory drugs, along with high-dose chemotherapy and autologous haematopoietic stem cell transplantation, have led to rapid and deep suppression of amyloid light chain production in the majority of patients. However, effective therapies for patients with advanced cardiac involvement are an unmet need. Passive immunotherapies targeting clonal plasma cells and directly accelerating removal of amyloid deposits promise to further improve the overall outlook of this increasingly treatable disease.
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Jain T, Kosiorek HE, Kung ST, Shah VS, Dueck AC, Gonzalez-Calle V, Luft S, Reeder CB, Adams R, Noel P, Larsen JT, Mikhael J, Bergsagel L, Stewart AK, Fonseca R. Treatment With Bortezomib-based Therapy, Followed by Autologous Stem Cell Transplantation, Improves Outcomes in Light Chain Amyloidosis: A Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:486-492.e1. [DOI: 10.1016/j.clml.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/19/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
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Sidiqi MH, Aljama MA, Buadi FK, Warsame RM, Lacy MQ, Dispenzieri A, Dingli D, Gonsalves WI, Kumar S, Kapoor P, Kourelis T, Hogan WJ, Gertz MA. Stem Cell Transplantation for Light Chain Amyloidosis: Decreased Early Mortality Over Time. J Clin Oncol 2018; 36:1323-1329. [DOI: 10.1200/jco.2017.76.9554] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Autologous stem-cell transplantation (ASCT) has been used in patients with immunoglobulin light chain (AL) amyloidosis for more than two decades. Early experience raised concerns regarding safety with high early-mortality rates. Patients and Methods We report 20 years of experience with ASCT for AL amyloidosis at the Mayo Clinic Rochester. In all, 672 consecutive patients receiving ASCT for AL amyloidosis were divided into three cohorts on the basis of date of transplantation (cohort 1, 1996-2002 [n = 124]; cohort 2, 2003-2009 [n = 302]; and cohort 3, 2010-2016 [n = 246]). Results The median age for the entire cohort was 59 years, with patients in cohort 3 being slightly older than those in the other two cohorts (60 v 58 v 54 years for cohorts 3, 2, and 1, respectively; P < .001). Fewer patients in cohort 3 had more than two organs involved (9% v 18% v 19% for cohorts 3, 2, and 1, respectively; P < .001). More patients received pretransplantation therapy in cohort 3 compared with earlier time periods (49% v 38% v 42% for cohorts 3, 2, and 1, respectively; P = .02). Hematologic response was higher in cohort 3 (84% v 79% v 69% for cohorts 3, 2, and 1, respectively; P = .002). Median overall survival for the entire cohort was 122 months and improved over time (not reached v 120 months v 75 months for cohorts 3, 2, and 1, respectively; P < .001). Treatment-related mortality declined over time (2.4% v 8.6% v 14.5% for cohorts 3, 2, and 1, respectively; P < .001). On multivariable analysis, conditioning dose, Mayo stage 2012, and hematologic response were independent predictors of survival. Conclusion ASCT is a highly effective therapy for AL amyloidosis. The improved survival and markedly reduced treatment-related mortality in eligible patients indicate that this will remain an important first-line option even in the era of treatment approaches that use novel agents.
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Affiliation(s)
| | | | | | | | | | | | - David Dingli
- All authors: Mayo Clinic Rochester, Rochester, MN
| | | | - Shaji Kumar
- All authors: Mayo Clinic Rochester, Rochester, MN
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Ramírez-Arroniz JC, Martínez Klimova E, Pedro-Hernández LD, Organista-Mateos U, Cortez-Maya S, Ramírez-Ápan T, Nieto-Camacho A, Calderón-Pardo J, Martínez-García M. Water-soluble porphyrin-PAMAM-conjugates of melphalan and their anticancer activity. Drug Dev Ind Pharm 2018. [PMID: 29521131 DOI: 10.1080/03639045.2018.1449857] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
p-[bis(chloro-2-ethyl)amino]-L-phenylalanine (melphalan) is an approved anti-cancer agent with a broad spectrum of antitumor activity. However, it has some disadvantages, such as poor water-solubility followed by rapid elimination, which reduce the target specificity. To solve these problems, porphyrin- poly(amidoamine) or PAMAM-conjugates of melphalan were synthesized and characterized. The dendrimeric conjugates showed satisfactory water solubility. It was found that the size of the dendrimer played a crucial role in controlling the drug content and diameter of the melphalan-conjugates. The in vitro studies of cell cytotoxicity revealed that by employing the dendrimeric conjugation strategy and using the PAMAM dendritic arms as spacers, the conjugates had good anti-cancer activity and lower toxicity than free melphalan.
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Affiliation(s)
- Julio César Ramírez-Arroniz
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Elena Martínez Klimova
- b Instituto de Fisiología Celular , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Luis Daniel Pedro-Hernández
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Ulises Organista-Mateos
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Sandra Cortez-Maya
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Teresa Ramírez-Ápan
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Antonio Nieto-Camacho
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - José Calderón-Pardo
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
| | - Marcos Martínez-García
- a Instituto de Química , Universidad Nacional Autónoma de México, Ciudad Universitaria , México D.F. , México
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Wong SW, Toskic D, Warner M, Varga C, Moreno-Koehler A, Fein D, Fogaren T, Lee L, Oliver CM, Guthrie SD, Comenzo RL. Primary Amyloidosis With Renal Involvement: Outcomes in 77 Consecutive Patients at a Single Center. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:759-766. [DOI: 10.1016/j.clml.2017.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/08/2017] [Indexed: 01/20/2023]
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Cowan AJ, Klippel ZK, Stevenson PA, Hyun TS, Tuazon S, Becker PS, Green DJ, Holmberg LA, Coffey DG, Gopal AK, Libby EN. Pre-transplantation novel agent induction predicts progression-free survival for patients with immunoglobulin light-chain amyloidosis undergoing high-dose melphalan and autologous stem cell transplantation. Amyloid 2016; 23:254-259. [PMID: 27879147 PMCID: PMC5189710 DOI: 10.1080/13506129.2016.1258356] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION High-dose melphalan and autologous stem cell transplantation (HDM/SCT) is an effective treatment modality for immunoglobulin light-chain (AL) amyloidosis; however, its application remains restricted to patients with good performance status and limited organ involvement. In recent years, the paradigm for AL amyloidosis has changed with the introduction of novel agents such as immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs). We hypothesized that use of novel agent induction regimens has improved outcomes for patients with AL amyloidosis undergoing HDM/SCT at our center. METHODS All patients with AL amyloidosis, age ≥18 years who underwent HDM/SCT between 2001 and 2014 at the Fred Hutchinson Cancer Research Center and University of Washington Medical Center were included in this study. Any regimen administered within 6 months prior to HDM/SCT including an IMiD or a PI was considered a novel induction regimen. Use of induction regimen was evaluated in a Cox proportional hazard model for association with progression-free survival (PFS) and overall survival (OS). RESULTS Forty-five patients with AL amyloidosis underwent HDM/SCT. The median age was 57.2 years (range 39-74.4), 15 (33.3%) were women. The median number of organs involved was 2 (range 1-5), with 20 patients having only 1 (44.4%), 10 patients having 2 (22.2%), and 15 patients (33.3%) having ≥ 3 organs involved. Novel agent induction regimens were used prior to HDM/SCT in 21 patients (46.7%); these comprised PI in 13/21 (57.1%), IMiD alone in 6/21 (28.6%), PI and cyclophosphamide (CyBorD) in 3/21 (14.3%), and IMiD and PI in 3/21 (14.3%). Use of a novel agent induction regimen was associated with improved, but not OS. The 3-year PFS for patients who received a novel agent induction was 79%, while for those who did not was 53% (hazard ratio [HR] = 0.317, p = 0.048). The 3-year OS for patients who received novel agent induction regimens was 95%, while for those who did not was 71% (HR = 0.454, p = 0.247). DISCUSSION Our data suggest that use of a novel agent induction regimen including an IMiD or PI prior to HDM/SCT for patients with AL amyloidosis could improve outcomes, with improvement in PFS. Although these results are limited by sample size and lack of randomization, these results support possible further investigation of novel agent induction regimens in the context of a prospective clinical trial.
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Affiliation(s)
- Andrew J Cowan
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | | | - Philip A Stevenson
- b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Teresa S Hyun
- b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,d Department of Pathology , University of Washington , Seattle , WA , USA , and
| | - Sherilyn Tuazon
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Pamela S Becker
- b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,e Division of Hematology , Department of Medicine, University of Washington , Seattle , WA , USA
| | - Damian J Green
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Leona A Holmberg
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - David G Coffey
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Ajay K Gopal
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
| | - Edward N Libby
- a Division of Medical Oncology , University of Washington , Seattle , WA , USA.,b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA
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Hwa YL, Kumar SK, Gertz MA, Lacy MQ, Buadi FK, Kourelis TV, Gonsalves WI, Rajkumar SV, Go RS, Leung N, Kapoor P, Dingli D, Kyle RA, Russell S, lust JA, Hayman SR, Lin Y, Zeldenrust S, Dispenzieri A. Induction therapy pre-autologous stem cell transplantation in immunoglobulin light chain amyloidosis: a retrospective evaluation. Am J Hematol 2016; 91:984-8. [PMID: 27341539 DOI: 10.1002/ajh.24453] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/17/2016] [Indexed: 11/10/2022]
Abstract
There is no consensus on whether patients with immunoglobulin light chain amyloidosis (AL) should receive induction therapy prior to an autologous stem cell transplant (ASCT). This study investigated the relationships between baseline bone marrow plasmacytosis (BMPC), cardiac staging, and pre-transplant induction in AL patients. All patients who received ASCT for AL within 12 months of diagnosis were included. Patient characteristics and outcomes were abstracted. Univariate and multivariate modeling was performed. Among 415 AL patients, 35% had induction prior to ASCT. Post-ASCT hematologic CR plus VGPR rates were significantly higher in those with baseline BMPC ≤ 10% compared to BMPC >10% (58% versus 40%, P = 0.0013). Significant risk factors for lack of attainment of CR included attenuated dose melphalan conditioning, baseline BMPC > 10%, no induction, and male gender. The 5-year OS for the entire group was 65%. On multivariate analysis, risk factors for inferior OS included no induction therapy, advanced AL amyloid staging, BMPC > 10%, attenuated conditioning melphalan dose, and male gender. Patients with Mayo 2012 stage I-II patients with BMPC ≤ 10%, who comprised 56% of the ASCT population fared exceedingly well regardless of whether or not they received induction therapy with a 5-year OS of 81 to 83%. Induction therapy pre-ASCT may improve outcomes among AL patients due to a rapid reduction of toxic light chains or alternatively by elimination of less fit patients by "testing" their ability to tolerate chemotherapy. Prospective studies will be required to sort out these and other questions. Am. J. Hematol. 91:984-988, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Yi L. Hwa
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Shaji K. Kumar
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Martha Q. Lacy
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | | | | | | | - Ronald S. Go
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Nelson Leung
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - David Dingli
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | - Robert A. Kyle
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - John A. lust
- Division of Hematology; Mayo Clinic; Rochester Minnesota
| | | | - Yi Lin
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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Long-term event-free and overall survival after risk-adapted melphalan and SCT for systemic light chain amyloidosis. Leukemia 2016; 31:136-142. [PMID: 27560108 PMCID: PMC5220129 DOI: 10.1038/leu.2016.229] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/08/2016] [Accepted: 08/01/2016] [Indexed: 01/13/2023]
Abstract
Stem cell transplantation (SCT), an effective therapy for amyloid light chain (AL) amyloidosis patients, is associated with low treatment-related mortality (TRM) with appropriate patient selection and risk-adapted dosing of melphalan (RA-SCT). Consolidation after SCT increases hematologic complete response (CR) rates and may improve overall survival (OS) for patients with <CR. We retrospectively analyzed outcomes for 143 patients who underwent RA-SCT with or without consolidation. Melphalan was administered at 100 (14%), 140 (52%) and 200 (34%) mg/m2. The TRM rate at 100 days was 5%. RA-SCT resulted in CR in 24% (3 months) and 48% (12 months) of patients. The CR rate was particularly high (62%) in patients offered bortezomib consolidation. With a median follow-up among survivors of 7.7 years, median event-free survival (EFS) with RA-SCT was 4.04 years (95% confidence interval (CI): 3.41-5.01 years); median OS was 10.4 years (95% CI: 7.3-not achieved). Patients with CR at 12 months after SCT had significantly longer EFS (P=0.01) and OS (P=0.04). In a multivariate analysis, melphalan dose had no impact on EFS (P=0.26) or OS (P=0.11). For selected patients, RA-SCT was safe and was associated with extended long-term survival. With the availability of novel agents for consolidation, RA-SCT remains a very effective and important backbone treatment for AL amyloidosis.
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[Autologous peripheral blood hematopoietic stem cell transplantation for patients with primary light chain amyloidosis: experience of 31 cases in a single center]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:201-4. [PMID: 27033756 PMCID: PMC7342947 DOI: 10.3760/cma.j.issn.0253-2727.2016.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
目的 探讨自体外周血造血干细胞移植(ASCT)治疗原发性轻链型淀粉样变性的疗效和安全性。 方法 回顾性分析2009年1月至2015年6月接受ASCT治疗的31例原发性轻链型淀粉样变性患者的临床资料、疗效、生存及转归。 结果 31例患者中男18例、女13例,中位年龄55(43~66)岁;20例患者为单器官受累;80.6%的患者为Mayo 1期;诊断至ASCT的中位时间为3(0.5~26)个月;粒细胞植入和血小板植入的中位时间分别为11(9~12) d和11(8~14) d;无移植相关死亡病例。在可评价疗效的27例患者中,总体血液学缓解率为85.2%(23例),其中完全缓解率和非常好的部分缓解率分别为63.0%(17例)和7.4%(2例),获得最佳血液学缓解的中位时间为4(1~21)个月。总体器官缓解率为59.2%,获得器官缓解的中位时间为8(3~18)个月。中位随访21个月,1例患者死亡,3例患者出现疾病进展,预计的3年无进展生存率和总生存率分别为92.8%和96.4%。 结论 ASCT对于早期原发性轻链型淀粉样变性患者是一种有效、安全的治疗手段。
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Muchtar E, Buadi FK, Dispenzieri A, Gertz MA. Immunoglobulin Light-Chain Amyloidosis: From Basics to New Developments in Diagnosis, Prognosis and Therapy. Acta Haematol 2016; 135:172-90. [PMID: 26771835 DOI: 10.1159/000443200] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022]
Abstract
Immunoglobulin amyloid light-chain (AL) amyloidosis is the most common form of systemic amyloidosis, where the culprit amyloidogenic protein is immunoglobulin light chains produced by marrow clonal plasma cells. AL amyloidosis is an infrequent disease, and since presentation is variable and often nonspecific, diagnosis is often delayed. This results in cumulative organ damage and has a negative prognostic effect. AL amyloidosis can also be challenging on the diagnostic level, especially when demonstration of Congo red-positive tissue is not readily obtained. Since as many as 31 known amyloidogenic proteins have been identified to date, determination of the amyloid type is required. While several typing methods are available, mass spectrometry has become the gold standard for amyloid typing. Upon confirming the diagnosis of amyloidosis, a pursuit for organ involvement is essential, with a focus on heart involvement, even in the absence of suggestive symptoms for involvement, as this has both prognostic and treatment implications. Details regarding initial treatment options, including stem cell transplantation, are provided in this review. AL amyloidosis management requires a multidisciplinary approach with careful patient monitoring, as organ impairment has a major effect on morbidity and treatment tolerability until a response to treatment is achieved and recovery emerges.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minn., USA
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Abstract
Immunoglobulin light chain amyloidosis (AL) is a rare, complex disease caused by misfolded free light chains produced by a usually small, indolent plasma cell clone. Effective treatments exist that can alter the natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of AL amyloidosis are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. The suppression of the amyloidogenic light chains using the cardiac biomarkers as guide to choose chemotherapy is still the mainstay of therapy. There are exciting possibilities ahead, including the study of oral proteasome inhibitors, antibodies directed at plasma cell clone, and finally antibodies attacking the amyloid deposits are entering the clinic, offering unprecedented opportunities for radically improving the care of this disease.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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Abstract
The natural history of immunoglobulin light chain associated amyloidosis (AL) is determined by the extent of cardiac involvement. Patients with cardiac AL and symptomatic heart failure have a median survival of approximately six months without successful treatment of the underlying plasma cell disorder The outcome in cardiac AL is determined by both the severity of cardiac involvement and the response to treatment. Staging systems using cardiac biomarkers, including NT- proBNP and troponin, have been found to be powerful predictors of prognosis and are used to guide treatment. Arrhythmias are common in cardiac AL and may lead to acute hemodynamic compromise. Sudden cardiac death, often due to pulseless electrical activity, is an important cause of early mortality. Supportive therapy for heart failure is usually limited to diuretics. Beta-blockers, ACE-inhibitors, and angiotensin receptor blockers are poorly tolerated in cardiac AL and should be avoided. Cardiac transplantation is controversial and reserved for highly selected patients with limited extracardiac involvement. The primary target of treatment in cardiac AL is obliteration of the plasma cell clone, using chemotherapy alone or combined with autologous stem cell transplantation. Despite the risk of early mortality, overall survival has improved with advances in disease modifying therapy. Earlier diagnosis and treatment of cardiac AL is crucial to improving survival.
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Affiliation(s)
- Martha Grogan
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, MN, USA,
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Dispenzieri A, Buadi F, Kumar SK, Reeder CB, Sher T, Lacy MQ, Kyle RA, Mikhael JR, Roy V, Leung N, Grogan M, Kapoor P, Lust JA, Dingli D, Go RS, Hwa YL, Hayman SR, Fonseca R, Ailawadhi S, Bergsagel PL, Chanan-Khan A, Rajkumar SV, Russell SJ, Stewart K, Zeldenrust SR, Gertz MA. Treatment of Immunoglobulin Light Chain Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement. Mayo Clin Proc 2015; 90:1054-81. [PMID: 26250727 DOI: 10.1016/j.mayocp.2015.06.009] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/10/2015] [Accepted: 06/11/2015] [Indexed: 01/19/2023]
Abstract
Immunoglobulin light chain amyloidosis (AL amyloidosis) has an incidence of approximately 1 case per 100,000 person-years in Western countries. The rarity of the condition not only poses a challenge for making a prompt diagnosis but also makes evidenced decision making about treatment even more challenging. Physicians caring for patients with AL amyloidosis have been borrowing and customizing the therapies used for patients with multiple myeloma with varying degrees of success. One of the biggest failings in the science of the treatment of AL amyloidosis is the paucity of prospective trials, especially phase 3 trials. Herein, we present an extensive review of the literature with an aim of making recommendations in the context of the best evidence and expert opinion.
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Affiliation(s)
| | | | | | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Tamur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | | | | | | | - Keith Stewart
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
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Sanchorawala V, Brauneis D, Shelton AC, Lo S, Sun F, Sloan JM, Quillen K, Seldin DC. Induction Therapy with Bortezomib Followed by Bortezomib-High Dose Melphalan and Stem Cell Transplantation for Light Chain Amyloidosis: Results of a Prospective Clinical Trial. Biol Blood Marrow Transplant 2015; 21:1445-51. [PMID: 25858810 DOI: 10.1016/j.bbmt.2015.04.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/01/2015] [Indexed: 12/20/2022]
Abstract
The depth of hematologic response has been shown to correlate with survival and organ responses for patients with light chain (AL) amyloidosis. We conducted a prospective trial of 2 cycles of induction with bortezomib and dexamethasone on a twice a week schedule followed by conditioning with bortezomib and high-dose melphalan (HDM) and autologous stem cell transplantation (SCT). The objectives were hematologic responses, tolerability, and survival. Thirty-five patients were enrolled from 2010 to 2013. Of these, 30 proceeded with SCT, whereas 5 did not because of clinical deterioration during induction (n = 3) or complications after stem cell collection (n = 2). Two patients developed features of an autologous graft-versus-host disease-like syndrome post-SCT, which responded to steroids; no other unusual complications were seen. Treatment-related mortality occurred in 8.5% (3/35). Hematologic responses were achieved by 100% of the 27 assessable patients (63% complete response, 37% very good partial response [VGPR]) who completed the planned treatment. By intention-to-treat, hematologic responses occurred in 77% of patients (49% complete response, 29% VGPR). With a median follow-up of 36 months, the median overall survival and progression-free survival were not reached. In conclusion, incorporating bortezomib into induction and conditioning yielded a high rate of hematologic responses after HDM/SCT in patients with AL amyloidosis.
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Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.
| | - Dina Brauneis
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Anthony C Shelton
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stephen Lo
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Fangui Sun
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Karen Quillen
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - David C Seldin
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
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Wechalekar AD, Gillmore JD, Bird J, Cavenagh J, Hawkins S, Kazmi M, Lachmann HJ, Hawkins PN, Pratt G. Guidelines on the management of AL amyloidosis. Br J Haematol 2014; 168:186-206. [PMID: 25303672 DOI: 10.1111/bjh.13155] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hayashi T, Ikeda H, Igarashi T, Maruyama Y, Aoki Y, Nojima M, Ishida T, Shinomura Y. Autologous stem cell transplantation for AL amyloidosis: adjustment of melphalan dose by factors including BNP. Int J Hematol 2014; 100:554-8. [PMID: 25281404 DOI: 10.1007/s12185-014-1680-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 09/19/2014] [Accepted: 09/21/2014] [Indexed: 11/26/2022]
Abstract
High-dose melphalan with autologous stem cell transplantation (HDM/ASCT) is a promising treatment option for eligible patients with systemic immunoglobulin light chain (AL) amyloidosis. We present the results of ASCT following risk-adapted melphalan conditioning on the basis of criteria proposed by our group, including B-type natriuretic peptide (BNP). Ten patients with primary systemic AL amyloidosis treated at our institute were evaluated. A full dose of melphalan (200 mg/m(2)) was administered to patients who met all the following: performance status, 0 or 1; number of organs involved, 2 or less; serum creatinine, 1.5 mg/dL or less; EF 50 % or more and BNP 200 pg/mL or less; otherwise 140 mg/m(2). The hematologic complete response was achieved in four and organ response was seen in two patients. The median event-free survival (EFS) of all patients was 21.5 months, and median overall survival (OS) was 47.0 months. EFS and OS were significantly longer for patients who received 200 mg/m(2) of melphalan than for those who received lower dose (EFS: not reached vs. 13.9 months, P = 0.0217; OS: not reached vs. 13.8 months, P = 0.0186). No treatment-related mortality within 100 days from ASCT was observed. Evaluation of cardiac diastolic function may contribute to safer HDM/ASCT and improve outcome of AL amyloidosis.
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Affiliation(s)
- Toshiaki Hayashi
- Department of Gastroenterology, Rheumatology, and Clinical Immunology, Sapporo Medical University School of Medicine, South 1, West 16, Chuou-ku, Sapporo, Hokkaido, Japan,
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Scott EC, Heitner SB, Dibb W, Meyers G, Smith SD, Abar F, Kovacsovics T, Perez-Avraham G, Stentz A, Frires R, Dibb J, Maziarz RT. Induction Bortezomib in AL Amyloidosis Followed By High Dose Melphalan and Autologous Stem Cell Transplantation: A Single Institution Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:424-430.e1. [DOI: 10.1016/j.clml.2014.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/03/2014] [Accepted: 02/11/2014] [Indexed: 11/29/2022]
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Sanchorawala V. High dose melphalan and autologous peripheral blood stem cell transplantation in AL amyloidosis. Hematol Oncol Clin North Am 2014; 28:1131-44. [PMID: 25459183 DOI: 10.1016/j.hoc.2014.08.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AL amyloidosis is the most common form of systemic amyloidosis and is associated with an underlying plasma cell dyscrasia. It is often difficult to recognize because of its many manifestations. Recent diagnostic and prognostic advances include the serum-free light chain assay, cardiac MRI, and serologic cardiac biomarkers. Treatment strategies that have evolved during the past decade are prolonging survival and preserving organ function. This article outlines the role of high-dose melphalan and stem cell transplantation. This year marks the 20th anniversary for the first patient who underwent successful stem cell transplantation for this disease at Boston Medical Center.
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Affiliation(s)
- Vaishali Sanchorawala
- Stem Cell Transplantation Program, Section of Hematology and Oncology, Amyloidosis Center, Boston Medical Center, 820 Harrison Avenue, FGH-1007, Boston, MA 02118, USA.
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Halwani O, Delgado DH. Cardiac amyloidosis: an approach to diagnosis and management. Expert Rev Cardiovasc Ther 2014; 8:1007-13. [DOI: 10.1586/erc.10.41] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Huang X, Wang Q, Chen W, Zeng C, Chen Z, Gong D, Zhang H, Liu Z. Induction therapy with bortezomib and dexamethasone followed by autologous stem cell transplantation versus autologous stem cell transplantation alone in the treatment of renal AL amyloidosis: a randomized controlled trial. BMC Med 2014; 12:2. [PMID: 24386911 PMCID: PMC3895846 DOI: 10.1186/1741-7015-12-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 12/06/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Although the use of bortezomib alone and in combination with steroids has shown efficacy in AL amyloidosis, its role in combination with high-dose melphalan and autologous stem cell transplantation (HDM/SCT) is unknown. In this study, we evaluated bortezomib in combination with dexamethasone (BD) for induction chemotherapy prior to HDM/SCT. METHODS This was a single-center, prospective, randomized controlled trial comparing induction therapy consisting of two BD cycles followed by HDM/SCT (BD + HDM/SCT) with HDM/SCT alone in the treatment of patients with newly diagnosed AL amyloidosis. The hematological and organ responses of the patients were assessed every three months post HDM/SCT. RESULTS Fifty-six patients newly diagnosed with renal (100%), cardiac (57.1%), liver (7.1%), or nervous system (8.9%) AL amyloidosis were enrolled in this study; 28 patients were assigned to each arm. Two patients died within 100 days of HDM/SCT (3.6% treatment-related mortality). The overall hematologic response rates in the BD + HDM/SCT arm and HDM/SCT arm at three, six and twelve months were 78.5% versus 50%, 82.1% versus 53.5% and 85.7% versus 53.5%, respectively. In the BD + HDM/SCT arm, 15 (53.5%) patients achieved a hematologic response after BD and before HDM/SCT. An intention-to-treat analysis revealed a higher rate of complete remission in the BD + HDM/SCT arm at both 12 and 24 months (67.9% and 70%, respectively) than with the HDM/SCT-only therapy (35.7% and 35%, respectively, P = 0.03). After a median follow-up of 28 months, the survival rates at 24 months post-treatment start were 95.0% in the BD + HDM/SCT group and 69.4% in the HDM/SCT alone group (P = 0.03). CONCLUSIONS Our preliminary data suggest that the outcome of treating AL amyloidosis with BD induction and HDM/SCT was superior to the outcome of the HDM/SCT treatment alone. TRIAL REGISTRATION This trial has been registered at clinicaltrials.gov with the number NCT01998503.
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Affiliation(s)
| | | | | | | | | | | | | | - Zhihong Liu
- Research Institute of Nephrology, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China.
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Kim SJ, Lee GY, Jang HR, Choi JO, Kim JS, Kim HJ, Lee SY, Min JH, Jeon ES, Kim K. Autologous stem cell transplantation in light-chain amyloidosis patients: a single-center experience in Korea. Amyloid 2013; 20:204-11. [PMID: 23914780 DOI: 10.3109/13506129.2013.824417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Autologous stem cell transplantation (ASCT) has improved the prognosis of selected patients with immunoglobulin amyloid light-chain (AL) amyloidosis. However, there exist little data regarding Asian patients receiving ASCT. We retrospectively analyzed 24 patients who were treated with ASCT for AL amyloidosis between 2007 and 2012. The median age at the time of ASCT was 56 years (range: 40-62 years), and in 63% of patients, the AL amyloidosis involved two or more organs. All patients except one received induction treatment such as cyclophosphamide, dexamethasone or thalidomide before ASCT, but only approximately half of these patients showed a hematologic response. After ASCT, the overall hematologic response was increased to 92% (22/24), which translated into increased organ response in 58% of patients (14/24). There was no transplantation-related mortality (0%) even though cardiac amyloidosis patients were included in our series. In conclusion, our results of ASCT in patients with AL amyloidosis were comparable to that of Western countries in terms of response and survival outcomes. Therefore, ASCT is an effective and feasible treatment approach for Asian patients with AL amyloidosis.
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Affiliation(s)
- Seok Jin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine , Seoul , South Korea
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Perfetto F, Cappelli F, Bergesio F, Ciuti G, Porciani MC, Padeletti L, Moggi Pignone A. Cardiac amyloidosis: the heart of the matter. Intern Emerg Med 2013; 8:191-203. [PMID: 21739229 DOI: 10.1007/s11739-011-0647-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 06/14/2011] [Indexed: 01/01/2023]
Abstract
Amyloidosis comprises a unique group of diseases that share in common the extracellular deposition of insoluble fibrillar proteins in organs and tissue including the heart. Cardiac amyloidosis could be primary a part of systemic acquired amyloidosis, or a result of heredofamilial amyloidosis. Although the infiltration of the heart from different types of amyloid results in restrictive cardiomyopathy that manifests with refractory congestive heart failure and conduction abnormalities, unequivocal identification of the deposited amyloidogenic protein is mandatory in order to avoid misdiagnosis and inappropriate treatment. Recent developments in imaging techniques and extracardiac tissue biopsy have minimized the need for invasive endomyocardial biopsy for amyloidosis. Despite advances in treatment, the prognosis of a patient with amyloidosis is still poor and depends upon the underlying disease, and the type and degree of dysfunction of the involved organs. Thus, early diagnosis is mandatory because patients with advanced disease are usually too ill for intensive therapy. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
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Esplin BL, Gertz MA. Current Trends in Diagnosis and Management of Cardiac Amyloidosis. Curr Probl Cardiol 2013; 38:53-96. [DOI: 10.1016/j.cpcardiol.2012.11.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Dispenzieri A, Gertz MA, Buadi F. What do I need to know about immunoglobulin light chain (AL) amyloidosis? Blood Rev 2012; 26:137-54. [PMID: 22537397 DOI: 10.1016/j.blre.2012.03.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is the most common acquired systemic amyloidoses. Its presentation is often insidious and progressive, which may delay diagnosis. The interval between first symptoms and actual diagnosis along the intrinsic heterogeneity of tissue tropism create a wide spectrum of presentations, both in terms of scope and depth of symptoms and signs and functional status of patients. In this review, the authors review the pathogenesis, diagnosis and differential diagnosis of AL amyloidosis along with the prognosis and state-of-the-art management for patients with this affliction.
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Current status of hematopoietic cell transplantation in the treatment of systemic amyloid light-chain amyloidosis. Bone Marrow Transplant 2011; 47:895-905. [DOI: 10.1038/bmt.2011.152] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
Amyloidosis comprises a group of diseases characterized by the extracellular deposition of insoluble fibrillar proteins. This mechanism generates different clinical syndromes depending on the site and extent of organ involvement. Amyloidosis is classified into categories of systemic and localized disease. Systemic amyloidosis is further subdivided into a hereditary familial form (for example, ATTR amyloidosis), a reactive form (AA amyloidosis), dialysis-related (Abeta(2)M) amyloidosis and immunoglobulin light chain (AL) amyloidosis. Treatment can be symptomatic, directed at the affected organ, or can be directed at reducing the production of the abnormal proteins with different strategies. Despite advances in treatment, the prognosis is still poor and depends on the underlying disease as well as the type and degree of dysfunction in involved organs. Early diagnosis is essential because patients with advanced disease are generally unable to undergo intensive therapy. Patients with systemic amyloidosis often present to a rheumatologist not only because the disease can include musculoskeletal and articular symptoms but also because it can be associated with chronic rheumatic diseases. This Review discusses the clinical features of amyloidosis and its rheumatic manifestations. The various types of amyloidosis, as well their prognosis and treatment, are also presented.
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44
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Sen S, Sarsik B. A proposed histopathologic classification, scoring, and grading system for renal amyloidosis: standardization of renal amyloid biopsy report. Arch Pathol Lab Med 2010; 134:532-44. [PMID: 20367305 DOI: 10.5858/134.4.532] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT A disease associated with amyloid deposits, called amyloidosis, is associated with characteristic electron microscopic appearance, typical x-ray pattern, and specific staining. Renal involvement mainly occurs in AA amyloidosis and AL amyloidosis and usually progresses to renal failure. OBJECTIVE The renal histopathologic changes with amyloidosis comprise a spectrum. Clear relationships between the extent of amyloid deposition and the severity of clinical manifestations have not been demonstrated. Whether there is a lack of clinicopathologic correlation is not clear, but studies have revealed the need for standardization of the renal amyloid biopsy report. With these objectives in mind, we proposed a histopathologic classification, scoring, and grading system. Renal amyloidosis was divided into 6 classes, similar to the classification of systemic lupus erythematosus. Amyloid depositions and other histopathologic lesions were scored. The sum of these scores was termed the renal amyloid prognostic score and was divided into 3 grades. DATA SOURCES AA amyloidosis was detected in 90% of cases, mostly related to familial Mediterranean fever. Positive correlations between class I and grade I, class VI and grade III, and class III and grade II were observed. Also, a positive correlation was identified between severity of glomerular amyloid depositions, interstitial fibrosis, and inflammation. Because of the inadequacy of the patients' records and outcomes, different therapy regimes, and etiologies, clinical validation of this study has not been completed. CONCLUSIONS Standardization of the renal amyloid pathology report might be critical for patients' medication and comparison of outcome and therapeutic trials between different clinics. Because of our AA to AL amyloidosis ratio and the predisposition of familial Mediterranean fever-related AA amyloidosis, there is a need for further international collaborative studies.
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Affiliation(s)
- Sait Sen
- Pathology Department, Ege University School of Medicine, Bornova Izmir, Turkey.
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Short and long-term outcome of treatment with high-dose melphalan and stem cell transplantation for multiple myeloma-associated AL amyloidosis. Ann Hematol 2009; 89:579-84. [DOI: 10.1007/s00277-009-0874-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Accepted: 11/23/2009] [Indexed: 10/20/2022]
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Mhaskar R, Kumar A, Behera M, Kharfan-Dabaja MA, Djulbegovic B. Role of High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation in Primary Systemic Amyloidosis: A Systematic Review. Biol Blood Marrow Transplant 2009; 15:893-902. [DOI: 10.1016/j.bbmt.2009.01.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 01/26/2009] [Indexed: 10/20/2022]
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Frossard V, Ketterer N, Rosselet A, Meier P, Cairoli A, Duchosal MA, Kovacsovics T. Early intensification and autologous stem cell transplantation in patients with systemic AL amyloidosis: a single-centre experience. Ann Hematol 2008; 88:681-5. [PMID: 19066891 DOI: 10.1007/s00277-008-0652-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 11/20/2008] [Indexed: 11/25/2022]
Abstract
Primary systemic amyloidosis (AL amyloidosis) continues to have a very poor prognosis. Most therapeutic strategies remain unsatisfactory. Conventional chemotherapy is known to offer at best only moderate efficacy. Several studies have yielded higher complete response rates after high-dose chemotherapy and autologous stem cell transplantation (ASCT) in addition to improving outcomes in a subgroup of patients. However, the superiority of an intensive approach in AL amyloidosis has not been confirmed in a randomised trial. The precise role of ASCT remains unclear. We report our experience in 16 patients diagnosed with AL amyloidosis and treated in a multidisciplinary approach with high-dose melphalan and ASCT. Median age was 59 (39-71) years. The kidneys were predominantly affected in 75% of cases; two or more organs were affected in 38%. Median time from diagnosis to transplantation was 2 (1-4) months. Three patients (19%) developed acute renal failure and required transient dialysis. Transplant-related mortality was 6% after 100 days. Haematological complete response (CR) was obtained in nine (56%) and organ response in six (38%) patients. Nine out of 12 patients (75%) with kidney involvement exhibited a sustained clinical benefit at 12 months. Half of all the patients (n = 8) were alive after a median follow-up of 33 months, including two in continuous CR. This suggests that high-dose chemotherapy and ASCT are still valid treatment options in AL amyloidosis and that a significant number of patients with renal involvement might benefit from this approach.
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Affiliation(s)
- Valérie Frossard
- Department of Haematology, University Hospital CHUV, Lausanne, Switzerland
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48
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Lebovic D, Hoffman J, Levine BM, Hassoun H, Landau H, Goldsmith Y, Maurer MS, Steingart RM, Cohen AD, Comenzo RL. Predictors of survival in patients with systemic light-chain amyloidosis and cardiac involvement initially ineligible for stem cell transplantation and treated with oral melphalan and dexamethasone. Br J Haematol 2008; 143:369-73. [PMID: 18691169 DOI: 10.1111/j.1365-2141.2008.07327.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The treatment of systemic light-chain (AL) amyloidosis with symptomatic cardiac involvement at diagnosis remains a challenge. We report the results of 40 consecutive newly diagnosed AL cardiac patients who were not candidates for stem cell transplant and therefore received monthly oral melphalan and dexamethasone. Median survival was 10.5 months and baseline predictors of survival included gender, troponin I and interventricular septal thickness. The most significant predictor of survival was response to therapy. The haematological response rate was 58% (23/40) with 13% (5/40) complete responses; most responses were noted in <3 cycles. Achievement of a rapid response to therapy extends survival.
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Affiliation(s)
- D Lebovic
- Department of Medicine, Weill-Cornell School of Medicine, New York Hospital, NY, USA
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Dimopoulos M, Kastritis E. High dose therapy for light chain amyloidosis: can we reduce treatment related mortality further? Leuk Lymphoma 2008; 49:4-5. [PMID: 18203000 DOI: 10.1080/10428190701760078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Meletios Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Athens, Greece.
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Cohen AD, Zhou P, Chou J, Teruya-Feldstein J, Reich L, Hassoun H, Levine B, Filippa DA, Riedel E, Kewalramani T, Stubblefield MD, Fleisher M, Nimer S, Comenzo RL. Risk-adapted autologous stem cell transplantation with adjuvant dexamethasone +/- thalidomide for systemic light-chain amyloidosis: results of a phase II trial. Br J Haematol 2008; 139:224-33. [PMID: 17897298 DOI: 10.1111/j.1365-2141.2007.06783.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
High-dose melphalan (MEL) with autologous stem cell transplant (SCT) is an effective therapy for systemic AL amyloidosis (AL), but treatment-related mortality (TRM) has historically been high. We performed a phase II trial of risk-adapted SCT followed by adjuvant dexamethasone (dex) and thalidomide (thal) in an attempt to reduce TRM and improve response rates. Patients (n = 45) with newly diagnosed AL involving < or =2 organ systems were assigned to MEL 100, 140, or 200 mg/m(2) with SCT, based on age, renal function and cardiac involvement. Patients with persistent clonal plasma cell disease 3 months post-SCT received 9 months of adjuvant thal/dex (or dex if there was a history of deep vein thrombosis or neuropathy). Organ involvement was kidney (67%), heart (24%), liver/GI (22%) and peripheral nervous system (18%), with 31% having two organs involved. TRM was 4.4%. Thirty-one patients began adjuvant therapy, with 16 (52%) completing 9 months of treatment and 13 (42%) achieving an improvement in haematological response. By intention-to-treat, overall haematological response rate was 71% (36% complete response), with 44% having organ responses. With a median follow-up of 31 months, 2-year survival was 84% (95% confidence interval: 73%, 94%). Risk-adapted SCT with adjuvant thal/dex is feasible and results in low TRM and high haematological and organ response rates in AL patients.
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Affiliation(s)
- Adam D Cohen
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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