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Min YG, Han HJ, Shin HY, Baek JG, Kim JS, Park KS, Baek SH, Yoo I, Huh SY, Kwon YN, Choi SJ, Kim SM, Hong YH, Sung JJ. Therapeutic Outcomes and Electrophysiological Biomarkers in Anti-Myelin-Associated Glycoprotein Neuropathy: A Multicenter Cohort Study in South Korea. J Clin Neurol 2024; 20:50-58. [PMID: 38179632 PMCID: PMC10782088 DOI: 10.3988/jcn.2023.0127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/04/2023] [Accepted: 06/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Unlike other immune-mediated neuropathies, anti-myelin-associated glycoprotein (MAG) neuropathy is often refractory to immunotherapy. It is necessary to compare the relative efficacies of various immunotherapies and develop objective biomarkers in order to optimize its clinical management. METHODS This study recruited 91 patients with high anti-MAG antibody titers from 7 tertiary hospitals in South Korea. We analyzed the baseline characteristics, therapeutic outcomes, and nerve conduction study (NCS) findings of 68 patients and excluded 23 false positive cases. RESULTS The rate of positive responses to treatment was highest using zanubrutinib (50%) and rituximab (36.4%), followed by corticosteroids (16.7%), immunosuppressants (9.5%), intravenous immunoglobulin (5%), and plasma exchange (0%). Disability and weakness were significantly associated with multiple NCS parameters at the time of diagnosis, especially distal compound muscle action potential (CMAP) amplitudes. Moreover, the longitudinal trajectory of the average CMAP amplitudes paralleled the clinical courses, with a 16.2 percentile decrease as an optimal cutoff for predicting a clinical exacerbation (area under the receiver operating characteristic curve=0.792). CONCLUSIONS Our study supports the use of NCS as an objective marker for estimating disease burden and tracking clinical changes in patients with anti-MAG neuropathy. We have described the beneficial effects of rituximab and a new drug, zanubrutinib, compared with conventional immunotherapies.
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Affiliation(s)
- Young Gi Min
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Hee-Jo Han
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ha Young Shin
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Jong-Gyu Baek
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jun-Soon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kyung-Seok Park
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Seol-Hee Baek
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ilhan Yoo
- Department of Neurology, Nowon Eulji Medical Center, Seoul, Korea
| | - So-Young Huh
- Department of Neurology, Kosin Medical University Hospital, Busan, Korea
| | - Young Nam Kwon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seok-Jin Choi
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Ho Hong
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jung-Joon Sung
- Department of Translational Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
- Neuroscience Research Institute, Seoul National University College of Medicine, Seoul, Korea.
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Castellani F, Visentin A, Schirinzi E, Salvalaggio A, Cacciavillani M, Candiotto C, Baratè C, Cellini A, Bertorelle R, Siciliano G, Trentin L, Briani C. Mutational Profile in 75 Patients With Anti-Myelin-Associated Glycoprotein Neuropathy: Clinical and Hematologic Therapy Response and Hints on New Therapeutic Targets. NEUROLOGY(R) NEUROIMMUNOLOGY & NEUROINFLAMMATION 2023; 10:10/4/e200122. [PMID: 37137530 PMCID: PMC10155778 DOI: 10.1212/nxi.0000000000200122] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/13/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Neuropathy with antibodies to myelin-associated glycoprotein (MAG) is the most common paraproteinemic IgM neuropathy. Recently, the mutational profile of the MYD88 and CXCR4 genes has been included in the diagnostic workup of IgM monoclonal gammopathies. The objective of our study was to assess the prevalence of MYD88 L265P and CXCR4 S338X gene variants in patients with anti-MAG antibody neuropathy. Secondary aims were to evaluate possible correlations between the mutational profile and neuropathy severity, antibody titers, and treatment response. METHODS Seventy-five patients (47 men, mean age at molecular analysis 70.8 ± 10.2 years; mean disease duration 5.1 ± 4.9 years) with anti-MAG antibody neuropathy were recruited. Among them, 38 (50.7%) had IgM monoclonal gammopathy of undetermined significance, 29 (38.7%) Waldenstrom macroglobulinemia (WM), and 8 (10.6%) chronic lymphocytic leukemia/marginal zone lymphoma/hairy cell leukemia variant. Molecular analysis was performed on DNA from the bone marrow mononuclear cells in 55 of 75 patients and from peripheral mononuclear cells in 18 of 75 patients. Forty-five patients were treated with rituximab, 6 with ibrutinib, 2 with obinutuzumab-chlorambucil, and 3 with venetoclax-based therapy. All the patients were assessed with the Inflammatory Neuropathy Cause and Treatment (INCAT) Disability Scale, INCAT Sensory Sum Score, and MRC Sum Score at baseline and follow-up. We considered as responders, patients who improved by at least 1 point in 2 clinical scales. RESULTS Fifty patients (66.7%) carried the MYD88L265P variant, with a higher frequency in WM and naive patients (77.2% vs 33.3%, p = 0.0012). No patients harbored the CXCR4S338X variant. There were no significant differences in hematologic data (IgM levels, M protein, and anti-MAG antibody titers), neuropathy severity, or response to rituximab in MYD88-altered and MYD88 wild-type patients. Nine of 11 (81.8%) patients treated with novel targeted drug, according to the MYD88 status, responded to treatments. DISCUSSION MYD88L265P variant has a high prevalence (66.7%) in anti-MAG antibody neuropathy representing a potential effective mutational target for Bruton tyrosine kinase inhibitors. MYD88L265P variant, however, does not seem to be a prognostic factor of neuropathy severity or response to rituximab. In patients not responding or becoming refractory to rituximab, a tailored therapy with new effective target therapies should be considered.
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Affiliation(s)
- Francesca Castellani
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Andrea Visentin
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Erika Schirinzi
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Alessandro Salvalaggio
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Mario Cacciavillani
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Cinzia Candiotto
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Claudia Baratè
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Alessandro Cellini
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Roberta Bertorelle
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Gabriele Siciliano
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Livio Trentin
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy
| | - Chiara Briani
- From the Department of Neurosciences (F.C., A.S., Chiara Briani), Neurology Unit, University of Padova; Hematology and Clinical Immunology Unit (A.V., A.C., L.T.), Department of Medicine, University of Padova; Department of Clinical and Experimental Medicine (E.S., G.S.), Neurological Clinic, University of Pisa; EMG Lab (M.C.), CEMES, Synlab Group, Padova; Immunology and Molecular Oncology (C.C., R.B.), Veneto Institute of Oncology IOV-IRCCS, Padova; and Department of Clinical and Experimental Medicine (Claudia Baratè), Section of Hematology, University of Pisa, Italy.
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