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Gupta R, Jevremovic D, Mathew SJ, Kumar S. Multiparametric Flow Cytometry in the Evaluation of Plasma Cell Proliferative Disorders: Current Paradigms for Clinical Practice. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e88-e95. [PMID: 38142203 DOI: 10.1016/j.clml.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/25/2023]
Abstract
Diagnosis of plasma cell proliferative disorders (PCPDs) is primarily based on the demonstration of monoclonal protein (M-Protein) in blood and/ or urine which often precedes clinical manifestations of the disease. The basic pathophysiology behind the M-protein presence is the proliferation of clonal plasma cells (PCs) in bone marrow or extramedullary sites and is assessed using cytomorphology and immunophenotyping. The role of multiparametric flow cytometry (MFC) for PC identification is technically the most valuable tool in this context as it characterizes as well as quantifies the clonal PCs based on differential expression of various immunophenotypic (IPT) markers. From a diagnostic perspective, MFC is critical in the definite identification of the clonal PCs and delineates benign and borderline entities at one end of the spectrum (MGUS, SMM) with lower clonal PC% and, malignant diseases at the other end (MM and PCL) with higher clonal PC fraction. The role of MFC in assessment of measurable residual disease (MRD) and monitoring of progression in MM and various PCPDs has been validated in multiple clinical studies and is probably one of the most promising tools for predicting treatment outcomes. Furthermore, MFC also plays a crucial role in disease prognostication based on specific IPT profiles. An additional role of MFC in the current clinical scenario is the evaluation of tumor microenvironment based on immune cell repertoire, which is reflecting encouraging results across. Thus, in the current review we concisely describe the role of MFC as a reliable and essential modality in PCPDs, from diagnosis to prediction of treatment outcome and disease monitoring.
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Affiliation(s)
- Ritu Gupta
- Department of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India; Department of Hematology, Mayo Clinic, Rochester, MN.
| | - Dragan Jevremovic
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | | | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN
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Carlisi M, Presti RL, Plano F, Mancuso S, Siragusa S, Caimi G. Changes in RDW according to prognostic predictors in newly diagnosed multiple myeloma. Sci Rep 2024; 14:2832. [PMID: 38310176 PMCID: PMC10838310 DOI: 10.1038/s41598-024-53385-6] [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: 06/25/2023] [Accepted: 01/31/2024] [Indexed: 02/05/2024] Open
Abstract
RDW is an erythrocyte index that increase in multiple myeloma, in which it appears to have an important role in predicting outcome. For this reason, we performed a retrospective analysis to evaluate the relationships of RDW with some important prognostic predictors. Specifically, in a cohort of 190 newly diagnosed multiple myeloma patients, we have examined the behaviour of RDW and its trend in relation to the ISS stage and other prognostic factors, such as albumin, beta-2 microglobulin, LDH and bone marrow plasma cell infiltration. We performed the analysis in the entire cohort of patients and in the three different disease isotypes (Light chain, IgA, and IgG multiple myeloma). The evaluation of RDW in the different isotypes was made with the Kruskal-Wallis test, integrated by the Dunn test. The comparison between the subgroups allocated above and below the median value of each prognostic factor, was made with the Mann-Whitney test. From our analysis, we observed that RDW is higher in the IgA multiple myeloma, and it increases significantly from ISS I to III. Moreover, RDW increases in the presence of lower albumin values, higher levels of beta2-microglobulin and LDH and in the presence of a greater bone marrow plasma cell infiltrate.
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Affiliation(s)
- Melania Carlisi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy.
| | - R Lo Presti
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - F Plano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - S Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - S Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
| | - G Caimi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Via del Vespro 129, 90127, Palermo, Italy
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Drayson M, Jennis T, Laketic-Ljubojevic I, Patel D, Pratt G, Renwick S, Richter A, Wheeler R, Sheldon J, Sadler R, Stapleton M, Willis F, Whiston M. Laboratory practice is central to earlier myeloma diagnosis: Utilizing a primary care diagnostic tool and laboratory guidelines integrated into haematology services. Br J Haematol 2024; 204:476-486. [PMID: 38168756 DOI: 10.1111/bjh.19224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/13/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
Treatment advances have greatly improved survival, but myeloma is among the worst of all cancers for delayed diagnosis, causing serious morbidities and early deaths. This delay is largely because the symptom profile of myeloma has very low specificity, and in primary care, myeloma is rare. However, initiating the journey to diagnosis simply requires considering myeloma and sending blood to test for monoclonal immunoglobulin. Laboratory tests reliably detect monoclonal immunoglobulin, which is present in 99% of myeloma cases, so why do health care systems have such a problem with delayed diagnosis? The Myeloma UK early diagnosis programme has brought together diverse expertise to investigate this problem, and this article was prepared by the programme's working group for laboratory best practice. It reviews evidence for test requesting, analysis and reporting, for which there is large variation in practice across the United Kingdom. It presents a 'GP Myeloma diagnostic tool' and how it can be integrated into laboratory practice alongside a laboratory best practice tool. It proposes improved requesting and integration with haematology services for reporting and interpretation. Here the laboratory has a central role in creating efficient and cost-effective pathways for appropriate and timely bone marrow examination for myeloma diagnosis.
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Affiliation(s)
- Mark Drayson
- Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | | | | | - Dina Patel
- UK NEQAS Immunology, Immunochemistry & Allergy, Sheffield Teaching Hospitals, Sheffield, UK
| | - Guy Pratt
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Alex Richter
- Clinical Immunology Service, University of Birmingham, Birmingham, UK
| | - Rachel Wheeler
- Protein Reference Unit, South West London Pathology, St Georges Hospital, London, UK
| | - Joanna Sheldon
- Protein Reference Unit, South West London Pathology, St Georges Hospital, London, UK
| | - Ross Sadler
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Cárdenas MC, García-Sanz R, Puig N, Pérez-Surribas D, Flores-Montero J, Ortiz-Espejo M, de la Rubia J, Cruz-Iglesias E. Recommendations for the study of monoclonal gammopathies in the clinical laboratory. A consensus of the Spanish Society of Laboratory Medicine and the Spanish Society of Hematology and Hemotherapy. Part I: Update on laboratory tests for the study of monoclonal gammopathies. Clin Chem Lab Med 2023; 61:2115-2130. [PMID: 37477188 DOI: 10.1515/cclm-2023-0326] [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: 03/30/2023] [Accepted: 05/29/2023] [Indexed: 07/22/2023]
Abstract
Monoclonal gammopathies (MG) are characterized by the proliferation of plasma cells that produce identical abnormal immunoglobulins (intact or some of their subunits). This abnormal immunoglobulin component is called monoclonal protein (M-protein), and is considered a biomarker of proliferative activity. The identification, characterization and measurement of M-protein is essential for the management of MG. We conducted a systematic review of the different tests and measurement methods used in the clinical laboratory for the study of M-protein in serum and urine, the biochemistry and hematology tests necessary for clinical evaluation, and studies in bone marrow, peripheral blood and other tissues. This review included literature published between 2009 and 2022. The paper discusses the main methodological characteristics and limitations, as well as the purpose and clinical value of the different tests used in the diagnosis, prognosis, monitoring and assessment of treatment response in MG. Included are methods for the study of M-protein, namely electrophoresis, measurement of immunoglobulin levels, serum free light chains, immunoglobulin heavy chain/light chain pairs, and mass spectrometry, and for the bone marrow examination, morphological analysis, cytogenetics, molecular techniques, and multiparameter flow cytometry.
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Affiliation(s)
- María C Cárdenas
- Department of Clinical Analysis, Hospital Clinico San Carlos, Madrid, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - David Pérez-Surribas
- Laboratori Pasteur, Andorra La Vella, Andorra
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Juan Flores-Montero
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - María Ortiz-Espejo
- Department of Clinical Analysis, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Instituto de Investigación Sanitaria La Fe Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, Valencia, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Elena Cruz-Iglesias
- Department of Laboratory Medicine, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
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Ludwig H, Kainz S, Schreder M, Zojer N, Hinke A. SLiM CRAB criteria revisited: temporal trends in prognosis of patients with smoldering multiple myeloma who meet the definition of ‘biomarker-defined early multiple myeloma’—a systematic review with meta-analysis. EClinicalMedicine 2023; 58:101910. [PMID: 36969337 PMCID: PMC10033724 DOI: 10.1016/j.eclinm.2023.101910] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/27/2023] [Accepted: 02/27/2023] [Indexed: 03/22/2023] Open
Abstract
Background Biomarker-defined patients with smoldering multiple myeloma (SMM) were included in the diagnostic category of multiple myeloma (MM) by the International Myeloma Working Group (IMWG) in 2014. This includes ≥60% bone marrow plasma cells (BMPCs), free light chain ratio (FLCratio) ≥100, and >1 MRI-defined ≥5 mm focal lesion, also called SLiM CRAB MM. We examined whether the risk of progression of SLiM CRAB MM patients to CRAB positive MM described in recent studies differs from that reported in earlier studies published before the introduction of the new diagnostic criteria. Methods We conducted a systematic review with meta-analysis, and included studies on Embase and PubMed (01/01/2010-01/11/2022), selecting studies with digitizable progression curves. Inconsistent studies were excluded. We created forest plots using random effects models from digitized and published data and Kaplan-Meier curves. Main outcomes were median time to progression (TTP), 2-year progression risk, and odds ratios (ORs) comparing 2-year progression risks. Findings Our meta-analysis including 11 studies with 3482 patients found an approximately 3-fold longer TTP and 50% lower 2-year progression risk of SliM CRAB MM patients in recent (published after 2014) compared with earlier studies. Median TTP in patients with ≥60% BMPCs was 30.31 months [18.71-62.93] in recent compared with 9.20 months [6.02-15.56] in earlier studies; the 2-year progression risk was 45.45% [20.12-62.75] compared with 86.21% [65.74-94.45] in the respective time periods. In patients with a FLCratio ≥ 100, the median TTP was 48.06 months [40.51-64.91] vs. 15.33 months [9.38-19.10], and the 2-year progression risk was 31.61% [25.30-37.39] vs. 73.00% [62.39-80.62] in recent and earlier studies, respectively. Tests for heterogeneity showed that the two time periods differed significantly in their ORs when comparing patients who met the high-and low risk criteria. No appropriate recent studies on focal lesions have been published. Interpretation Recent studies show significantly improved prognosis of biomarker-defined MM with ≥60% BMPCs and FLCratio ≥ 100. This warrants careful evaluation for signs of progression before treatment initiation. Funding Funding was provided by the Austrian Forum against Cancer.
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Affiliation(s)
- Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o First Department of Medicine, Clinic Ottakring, Vienna, Austria
- Corresponding author. Wilhelminen Cancer Research Institute, c/o 1st Department of Medicine, Center for Oncology, Hematology and Palliative Care, Klinik Ottakring, Montleartstraße 37, 1160, Vienna, Austria.
| | - Sarah Kainz
- Wilhelminen Cancer Research Institute, c/o First Department of Medicine, Clinic Ottakring, Vienna, Austria
| | - Martin Schreder
- First Department of Medicine, Center for Oncology, Hematology, and Palliative Care, Clinic Ottakring, Vienna, Austria
| | - Niklas Zojer
- First Department of Medicine, Center for Oncology, Hematology, and Palliative Care, Clinic Ottakring, Vienna, Austria
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Cowan A, Ferrari F, Freeman SS, Redd R, El-Khoury H, Perry J, Patel V, Kaur P, Barr H, Lee DJ, Lightbody E, Downey K, Argyelan D, Theodorakakou F, Fotiou D, Liacos CI, Kanellias N, Chavda SJ, Ainley L, Sandecká V, Pospíšilová L, Minarik J, Jungova A, Radocha J, Spicka I, Nadeem O, Yong K, Hájek R, Kastritis E, Marinac CR, Dimopoulos MA, Get G, Trippa L, Ghobrial IM. Personalised progression prediction in patients with monoclonal gammopathy of undetermined significance or smouldering multiple myeloma (PANGEA): a retrospective, multicohort study. Lancet Haematol 2023; 10:e203-e212. [PMID: 36858677 PMCID: PMC9991855 DOI: 10.1016/s2352-3026(22)00386-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND Patients with precursors to multiple myeloma are dichotomised as having monoclonal gammopathy of undetermined significance or smouldering multiple myeloma on the basis of monoclonal protein concentrations or bone marrow plasma cell percentage. Current risk stratifications use laboratory measurements at diagnosis and do not incorporate time-varying biomarkers. Our goal was to develop a monoclonal gammopathy of undetermined significance and smouldering multiple myeloma stratification algorithm that utilised accessible, time-varying biomarkers to model risk of progression to multiple myeloma. METHODS In this retrospective, multicohort study, we included patients who were 18 years or older with monoclonal gammopathy of undetermined significance or smouldering multiple myeloma. We evaluated several modelling approaches for predicting disease progression to multiple myeloma using a training cohort (with patients at Dana-Farber Cancer Institute, Boston, MA, USA; annotated from Nov, 13, 2019, to April, 13, 2022). We created the PANGEA models, which used data on biomarkers (monoclonal protein concentration, free light chain ratio, age, creatinine concentration, and bone marrow plasma cell percentage) and haemoglobin trajectories from medical records to predict progression from precursor disease to multiple myeloma. The models were validated in two independent validation cohorts from National and Kapodistrian University of Athens (Athens, Greece; from Jan 26, 2020, to Feb 7, 2022; validation cohort 1), University College London (London, UK; from June 9, 2020, to April 10, 2022; validation cohort 1), and Registry of Monoclonal Gammopathies (Czech Republic, Czech Republic; Jan 5, 2004, to March 10, 2022; validation cohort 2). We compared the PANGEA models (with bone marrow [BM] data and without bone marrow [no BM] data) to current criteria (International Myeloma Working Group [IMWG] monoclonal gammopathy of undetermined significance and 20/2/20 smouldering multiple myeloma risk criteria). FINDINGS We included 6441 patients, 4931 (77%) with monoclonal gammopathy of undetermined significance and 1510 (23%) with smouldering multiple myeloma. 3430 (53%) of 6441 participants were female. The PANGEA model (BM) improved prediction of progression from smouldering multiple myeloma to multiple myeloma compared with the 20/2/20 model, with a C-statistic increase from 0·533 (0·480-0·709) to 0·756 (0·629-0·785) at patient visit 1 to the clinic, 0·613 (0·504-0·704) to 0·720 (0·592-0·775) at visit 2, and 0·637 (0·386-0·841) to 0·756 (0·547-0·830) at visit three in validation cohort 1. The PANGEA model (no BM) improved prediction of smouldering multiple myeloma progression to multiple myeloma compared with the 20/2/20 model with a C-statistic increase from 0·534 (0·501-0·672) to 0·692 (0·614-0·736) at visit 1, 0·573 (0·518-0·647) to 0·693 (0·605-0·734) at visit 2, and 0·560 (0·497-0·645) to 0·692 (0·570-0·708) at visit 3 in validation cohort 1. The PANGEA models improved prediction of monoclonal gammopathy of undetermined significance progression to multiple myeloma compared with the IMWG rolling model at visit 1 in validation cohort 2, with C-statistics increases from 0·640 (0·518-0·718) to 0·729 (0·643-0·941) for the PANGEA model (BM) and 0·670 (0·523-0·729) to 0·879 (0·586-0·938) for the PANGEA model (no BM). INTERPRETATION Use of the PANGEA models in clinical practice will allow patients with precursor disease to receive more accurate measures of their risk of progression to multiple myeloma, thus prompting for more appropriate treatment strategies. FUNDING SU2C Dream Team and Cancer Research UK.
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Affiliation(s)
- Annie Cowan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Federico Ferrari
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Biostatistics and Research Decision Sciences, Merck & Co, Rahway, NJ, USA
| | - Samuel S Freeman
- Bioinformatics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Robert Redd
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Habib El-Khoury
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Vidhi Patel
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Priya Kaur
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Hadley Barr
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David J Lee
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Katelyn Downey
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - David Argyelan
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Christine Ivy Liacos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Louise Ainley
- UCL Cancer Institute, University College London, London, UK
| | - Viera Sandecká
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Jiri Minarik
- Department of Hemato-Oncology, University Hospital Olomouc, Olomouc, Czech Republic
| | - Alexandra Jungova
- Department of Hematology and Oncology, University Hospital Pilsen, Pilsen, Czech Republic
| | - Jakub Radocha
- Fourth Department of Internal Medicine Hematology, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Charles University, Czech Republic
| | - Ivan Spicka
- First Department of Medicine, Department of Hematology, First Faculty of Medicine, Charles University and General Hospital in Prague, Czech Republic
| | - Omar Nadeem
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kwee Yong
- UCL Cancer Institute, University College London, London, UK
| | - Roman Hájek
- Fourth Department of Internal Medicine-Hematology, University Hospital in Ostrava, Ostrava, Czech Republic
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Gad Get
- Bioinformatics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lorenzo Trippa
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Irene M Ghobrial
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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Monoclonal Gammopathies of Clinical Significance: A Critical Appraisal. Cancers (Basel) 2022; 14:cancers14215247. [PMID: 36358666 PMCID: PMC9659226 DOI: 10.3390/cancers14215247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Monoclonal gammopathy of clinical significance (MGCS) refers to a recently coined term describing a complex and heterogeneous group of nonmalignant monoclonal gammopathies. These patients are characterized by the presence of a commonly small clone and the occurrence of symptoms that may be associated with the clone or with the monoclonal protein through diverse mechanisms. This is an evolving, challenging, and rapidly changing field. Patients are classified according to the key organ or system involved, with kidneys, skin, nerves, and eyes being the most frequently affected. However, multiorgan involvement may be the most relevant clinical feature at the presentation or during the course. This review delves into the definition, history, differential diagnosis, classification, prognosis, and treatment of this group of entities by analyzing the evidence accumulated to date from a critical perspective. Abstract Monoclonal gammopathies of clinical significance (MGCSs) represent a group of diseases featuring the association of a nonmalignant B cells or plasma cells clone, the production of an M-protein, and singularly, the existence of organ damage. They present a current framework that is difficult to approach from a practical clinical perspective. Several points should be addressed in order to move further toward a better understanding. Overall, these entities are only partially included in the international classifications of diseases. Its definition and classification remain ambiguous. Remarkably, its real incidence is unknown, provided that a diagnostic biopsy is mandatory in most cases. In fact, amyloidosis AL is the final diagnosis in a large percentage of patients with renal significance. On the other hand, many of these young entities are syndromes that are based on a dynamic set of diagnostic criteria, challenging a timely diagnosis. Moreover, a specific risk score for progression is lacking. Despite the key role of the clinical laboratory in the diagnosis and prognosis of these patients, information about laboratory biomarkers is limited. Besides, the evidence accumulated for many of these entities is scarce. Hence, national and international registries are stimulated. In particular, IgM MGCS deserves special attention. Until now, therapy is far from being standardized, and it should be planned on a risk and patient-adapted basis. Finally, a comprehensive and coordinated multidisciplinary approach is needed, and specific clinical trials are encouraged.
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Mateos MV, Hernández MT, Salvador C, Rubia JDL, de Arriba F, López-Corral L, Rosiñol L, Paiva B, Palomera L, Bargay J, Oriol A, Prosper F, López J, Arguiñano JM, Bladé J, Lahuerta JJ, San-Miguel J. Lenalidomide-dexamethasone versus observation in high-risk smoldering myeloma after 12 years of median follow-up time: A randomized, open-label study. Eur J Cancer 2022; 174:243-250. [PMID: 36067617 DOI: 10.1016/j.ejca.2022.07.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/23/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Smoldering multiple myeloma (SMM) is a heterogeneous disease in terms of progression to myeloma (MM), but its standard of care continues to be observation. METHODS The QuiRedex phase 3 trial initiated in 2007 included 119 high-risk patients with SMM randomized to treatment or observation. Treatment consisted of nine 4-week induction cycles (lenalidomide [Rd], 25 mg on days 1-21 plus dexamethasone, 20 mg on days 1-4 and 12-15), followed by maintenance (R, 10 mg on days 1-21) for up to 2 years. The primary end-point was time to progression (TTP) to myeloma based on per protocol population. Secondary end-points were overall survival (OS), response rate, and safety. An update of the trial after a long-term follow-up is presented here. This trial was registered with ClinicalTrials.gov (NCT00480363). FINDINGS After a median follow-up time of 12.5 years (range: 10.4-13.6), the median TTP to MM was 2.1 years in the observation arm and 9.5 years in the Rd arm (HR: 0.28, 95% CI: 0.18-0.44, p < 0.0001). The median OS was 8.5 years in the abstention arm and not reached in the Rd group (HR: 0.57, 95% CI: 0.34-0.95, p = 0.032). Patients who progressed received optimized treatments according to the standards of care, and the OS from progression was comparable in both arms (p = 0.96). INTERPRETATION This analysis confirms that early treatment with Rd for high-risk SMM translates into a sustained benefit in both TTP and OS. FUNDING Pethema (Spanish Program for the Treatment of Hematologic Diseases), Spain.
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Affiliation(s)
- María-Victoria Mateos
- Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Instituto de Biología Molecular y Celular del Cáncer (Universidad de Salamanca-Consejo Superior de Investigaciones Científicas), CIBERONC, Salamanca, Spain.
| | | | | | - Javier de la Rubia
- Hospital Universitario La Fe, Escuela de Medicina y Odontología, Universidad Católica de Valencia, CIBERONC CB16/12/00284, Spain
| | | | - Lucía López-Corral
- Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca, Instituto de Biología Molecular y Celular del Cáncer (Universidad de Salamanca-Consejo Superior de Investigaciones Científicas), CIBERONC, Salamanca, Spain
| | | | - Bruno Paiva
- Clínica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | | | - Joan Bargay
- Hospital Universitario Son LLatzer, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma Mallorca, Spain
| | | | - Felipe Prosper
- Clínica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Pamplona, Spain
| | | | | | - Joan Bladé
- Hospital Clinic, IDIBAPS, Barcelona, Spain
| | | | - Jesús San-Miguel
- Clínica Universidad de Navarra, CCUN, CIMA, IDISNA, CIBERONC, Pamplona, Spain
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9
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Van de Wyngaert Z, Boyle EM. Multiparameter flow cytometry in plasma cell disorders: when in doubt, go with the flow. Br J Haematol 2021; 196:1132-1133. [PMID: 34825361 DOI: 10.1111/bjh.17972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Zoé Van de Wyngaert
- Hématologie clinique et thérapie cellulaire, Hôpital Saint Antoine, APHP, Sorbonne Université, INSERM UMR 938, Paris, France
| | - Eileen M Boyle
- NYU Langone's Perlmutter Cancer Center, New-York, NY, USA
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10
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Sallustio F, Curci C, Solimando AG, Leone P, Pontrelli P, Gesualdo L, Vacca A, Racanelli V, Gallone A. Identification and monitoring of Copy Number Variants (CNV) in monoclonal gammopathy. Cancer Biol Ther 2021; 22:404-412. [PMID: 34288806 DOI: 10.1080/15384047.2021.1946458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) represents the pre-clinical stage of Multiple Myeloma (MM) with the 5% of MGUS progresses to MM. Although the progression from MGUS to MM has not been completely characterized, it is possible to monitor the DNA modifications of patients diagnosed with MGUS to detect early specific genomic abnormalities, including copy number variations (CNV). The CNVs of chromosome 1q and chromosome 13q are associated with a worse prognosis in MM.In the present study, we showed that it is possible to monitor the 1q21 gain and 13q deletion frequencies in gDNA using digital PCR. The CNV analysis of three cell lines with a well-characterized cytogenetic profile were compared with measures performed by a real-time PCR approach and with a digital PCR approach. Then, we analyzed CNVs in CD138+ plasma cells isolated from bone marrow of MGUS and MM patients.Our results show that digital PCR and targeted DNA monitoring represent a specific and accurate technique for the early detection of specific genomic abnormalities both in MM and in MGUS patients.Our results could represent a remarkable advancement in MM and MGUS diagnosis and in CNV analysis for the evaluation of the risk of progression from MGUS to MM.
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Affiliation(s)
- Fabio Sallustio
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Claudia Curci
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Antonio Giovanni Solimando
- Department of Biomedical Sciences and Human Oncology, Internal Medicine Unit "G. Baccelli", University of Bari Aldo Moro, Bari, Italy.,IRCCS Istituto Tumori Giovanni Paolo II of Bari, Italy
| | - Patrizia Leone
- Department of Biomedical Sciences and Human Oncology, Internal Medicine Unit "G. Baccelli", University of Bari Aldo Moro, Bari, Italy
| | - Paola Pontrelli
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy
| | - Angelo Vacca
- Department of Biomedical Sciences and Human Oncology, Internal Medicine Unit "G. Baccelli", University of Bari Aldo Moro, Bari, Italy
| | - Vito Racanelli
- Department of Biomedical Sciences and Human Oncology, Internal Medicine Unit "G. Baccelli", University of Bari Aldo Moro, Bari, Italy
| | - Anna Gallone
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
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11
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Baldursdóttir TR, Löve ÞJ, Gíslason GK, Björkholm M, Mellqvist UH, Lund SH, Blimark CH, Turesson I, Hultcrantz M, Landgren O, Kristinsson SY. Autoimmune disease is associated with a lower risk of progression in monoclonal gammopathy of undetermined significance. Eur J Haematol 2020; 106:380-388. [PMID: 33295006 DOI: 10.1111/ejh.13563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/03/2020] [Indexed: 01/01/2023]
Abstract
OBJECTIVES AND METHODS We conducted a population-based study including 19 303 individuals diagnosed with MGUS in Sweden from 1985 to 2013, with the aim to determine whether a prior history of autoimmune disease, a well-described risk factor for MGUS is a risk factor for progression of MGUS to multiple myeloma (MM) or lymphoproliferative diseases (LPs). Using the nationwide Swedish Patient registry, we identified MGUS cases with versus without an autoimmune disease present at the time of MGUS diagnosis and estimated their risk of progression. RESULTS A total of 5612 (29.1%) MGUS cases had preceding autoimmune diseases. Using Cox proportional hazards models, we found the risk of progression from MGUS to MM (HR = 0.83, 95% CI 0.73-0.94) and LPs (HR = 0.84, 95% CI 0.75-0.94) to be significantly lower in MGUS cases with prior autoimmune disease (compared to MGUS cases without). CONCLUSIONS In this large population-based study, a history of autoimmune disease was associated with a reduced risk of progression from MGUS to MM/other LPs. Potential underlying reason is that MGUS caused by chronic antigen stimulation is biologically less likely to undergo the genetic events that trigger progression. Our results may have implications in clinical counseling for patients with MGUS and underlying autoimmune disease.
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Affiliation(s)
| | - Þorvarður Jón Löve
- Landspítali, National University Hospital, Reykjavík, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Magnus Björkholm
- Department of Medicine, Division of Hematology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | - Malin Hultcrantz
- Department of Medicine, Division of Hematology, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,Myeloma Service, Division of Hematologic Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Ola Landgren
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Sigurður Yngvi Kristinsson
- Landspítali, National University Hospital, Reykjavík, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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12
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Changing paradigms in diagnosis and treatment of monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM). Leukemia 2020; 34:3111-3125. [PMID: 33046818 DOI: 10.1038/s41375-020-01051-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/18/2020] [Accepted: 09/29/2020] [Indexed: 12/13/2022]
Abstract
Multiple myeloma (MM) is a highly heterogenous disease that exists along a continuous disease spectrum starting with premalignant conditions monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) that inevitably precede MM. Over the past two decades, significant progress has been made in the genetic characterization and risk stratification of precursor plasma cell disorders. Indeed, the clinical introduction of highly effective and well-tolerated drugs begs the question: would earlier therapeutic intervention with novel therapies in MGUS and SMM patients alter natural history, providing a potential curative option? In this review, we discuss the epidemiology of MGUS and SMM and current models for risk stratification that predict MGUS and SMM progression to MM. We further discuss genetic heterogeneity and clonal evolution in MM and the interplay between tumor cells and the bone marrow (BM) microenvironment. Finally, we provide an overview of the current recommendations for the management of MGUS and SMM and discuss the open controversies in the field in light of promising results from early intervention clinical trials.
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13
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Sidiqi MH, Aljama M, Kumar SK, Jevremovic D, Buadi FK, Warsame R, Lacy MQ, Dingli D, Gonsalves WI, Fonder AL, Hobbs MA, Hwa YL, Kapoor P, Kourelis T, Leung N, Muchtar E, Lust JA, Kyle RA, Go RS, Rajkumar VS, Gertz MA, Dispenzieri A. The role of bone marrow biopsy in patients with plasma cell disorders: should all patients with a monoclonal protein be biopsied? Blood Cancer J 2020; 10:52. [PMID: 32376870 PMCID: PMC7203099 DOI: 10.1038/s41408-020-0319-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/04/2020] [Accepted: 04/17/2020] [Indexed: 01/24/2023] Open
Abstract
We conducted a retrospective review of multiple myeloma (MM), smoldering multiple myeloma (SMM), and monoclonal gammopathy of undetermined significance (MGUS) patients seen at Mayo Clinic to determine whether a bone marrow biopsy (BM) is necessary in all patients diagnosed with a monoclonal protein. A total of 2254 MM, 397 SMM, and 5836 MGUS patients were included in the study. A total of 29 (1.3%) MM patients “without CRAB/FLC” were identified where BM or advanced imaging was critical for diagnosis, 8 (0.3% MM cohort) of whom were diagnosed with MM solely on BM findings (plasma cells > 60%). Without BM or advanced imaging none of these patients would be classified low-risk MGUS. A total of 314 (79%) MGUS-like SMM patients were identified where classification of SMM was based on BM findings. Without BM 97 would be classified as low/low-intermediate-risk MGUS and 151 intermediate or high-risk MGUS; 66 had missing information precluding classification. Only three (<1% SMM cohort) were low-risk MGUS without abnormalities in hemoglobin, calcium, and renal function. In patients presenting with low-risk MGUS and normal hemoglobin, calcium, and renal function, the risk of missing a diagnosis of SMM and MM by omitting BM is <1%. BM should be deferred in these patients in preference to clinical and laboratory monitoring.
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Affiliation(s)
- M Hasib Sidiqi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Hematology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Mohammed Aljama
- Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahma Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amie L Fonder
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Miriam A Hobbs
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yi Lisa Hwa
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John A Lust
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert A Kyle
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ronald S Go
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vincent S Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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14
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Hájek R, Sandecka V, Špička I, Raab M, Goldschmidt H, Beck S, Minařík J, Pavlíček P, Radocha J, Heindorfer A, Jelínek T, Stejskal L, Brožová L, Ševčíková S, Straub J, Pika T, Pour L, Maisnar V, Seckinger A, Hose D. Identification of patients with smouldering multiple myeloma at ultra-high risk of progression using serum parameters: the Czech Myeloma Group model. Br J Haematol 2020; 190:189-197. [PMID: 32163180 DOI: 10.1111/bjh.16572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/18/2020] [Indexed: 12/31/2022]
Abstract
Smouldering multiple myeloma (SMM) presents without MM defining symptoms. We aimed to identify patients with SMM with an 80% risk of progression within 2 years using only serum parameters. In total, 527 patients with SMM were included and divided into a training group (287 patients from the Czech Myeloma Group [CMG]) and an independent validation group (240 patients from Heidelberg). The median follow-up was 2·4 and 2·5 years, respectively. Progression to MM occurred in 51·9% of the CMG and 38·8% of the Heidelberg patients, respectively. The median risk of progression was 11·0% (CMG) and 9·7% (Heidelberg) per year, during the 5 years after diagnosis. A serum involved/uninvolved free light-chain ratio of >30, immunoparesis, and serum monoclonal (M) protein of ≥2·3 g/dl emerged as powerful predictors of 2-year progression rate with a hazard ratio (HR) of 2·49 (95% confidence interval [CI] 1·49-4·17), HR of 2·01 (95% CI 1·36-2·96) and HR of 2·00 (95% CI 1·44-2·79) (P < 0·001) in univariate Cox regression analysis, respectively. Based on this, the CMG model identified patients with SMM with a 2-year risk of progression of 78·7% (95% CI 53·1-95·7; HR 6·8; P < 0·001, CMG) and 81·3% (95% CI 47·1-98·8; HR 38·63; P < 0·001, Heidelberg). Serum parameters in the CMG model allow identification of patients with SMM with an 80% risk of progression to symptomatic MM within 2 years.
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Affiliation(s)
- Roman Hájek
- Department of Hemato-Oncology, University Hospital, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Viera Sandecka
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Ivan Špička
- 1st Department of Medicine, 1st Faculty of Medicine, Charles University and General Hospital in Prague, Praha, Czech Republic
| | - Marc Raab
- Internal Medicine V and National Center for Tumor Diseases (NCT), University Clinic Heidelberg, Heidelberg, Germany
| | - Hartmut Goldschmidt
- Internal Medicine V and National Center for Tumor Diseases (NCT), University Clinic Heidelberg, Heidelberg, Germany
| | - Susanne Beck
- Labor für Myelomforschung, University Clinic Heidelberg, Heidelberg, Germany
| | - Jiří Minařík
- Department of Hemato-Oncology, University Hospital, Olomouc, Czech Republic
| | - Petr Pavlíček
- Department of Clinical Hematology, University Hospital Kralovske Vinohrady, Praha, Czech Republic
| | - Jakub Radocha
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Kralove, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Adriana Heindorfer
- Department of Clinical Hematology, Hospital Liberec, Liberec, Czech Republic
| | - Tomáš Jelínek
- Department of Hemato-Oncology, University Hospital, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Lukáš Stejskal
- Department of Hematology and Transfusion, Hospital Opava, Opava, Czech Republic
| | - Lucie Brožová
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Sabina Ševčíková
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic.,Babak Myeloma Group, Department of Pathophysiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Straub
- 1st Department of Medicine, 1st Faculty of Medicine, Charles University and General Hospital in Prague, Praha, Czech Republic
| | - Tomáš Pika
- Department of Hemato-Oncology, University Hospital, Olomouc, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Vladimír Maisnar
- 4th Department of Internal Medicine - Hematology, University Hospital Hradec Kralove, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Anja Seckinger
- Labor für Myelomforschung, University Clinic Heidelberg, Heidelberg, Germany
| | - Dirk Hose
- Labor für Myelomforschung, University Clinic Heidelberg, Heidelberg, Germany
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15
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Schürch CM, Rasche L, Frauenfeld L, Weinhold N, Fend F. A review on tumor heterogeneity and evolution in multiple myeloma: pathological, radiological, molecular genetics, and clinical integration. Virchows Arch 2019; 476:337-351. [PMID: 31848687 DOI: 10.1007/s00428-019-02725-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/12/2019] [Accepted: 11/25/2019] [Indexed: 01/03/2023]
Abstract
Recent research has dramatically advanced our understanding of the genetic basis of multiple myeloma (MM). MM displays enormous inter- and intratumoral heterogeneity, and underlies a clonal evolutionary process driven and shaped by diverse factors such as clonal competition, tumor microenvironment, host immunity, and therapy. Two main cytogenetic groups are distinguished: MM with recurrent translocations involving the immunoglobulin heavy chain locus and MM with hyperdiploidy involving the odd chromosomes. The disease virtually always starts with a preneoplastic prodromal phase-monoclonal gammopathy of undetermined significance-that variably progresses to symptomatic MM within a few months or many years. Tumor heterogeneity and its evolution in space and time have important consequences for the clinical management and outcome of MM patients. At diagnosis, spatial intratumoral heterogeneity poses a challenge for classification and risk stratification. During maintenance therapy, clonal evolution may complicate disease monitoring and promote drug resistance. Upon progression or transformation, identifying the dominant disease-driving neoplastic clones and elucidating their properties are key to tailor personalized therapy. In this review, we discuss tumor heterogeneity and clonal evolution in MM, integrating pathological, radiological, molecular genetics, and clinical data. Current and prospective classification schemes and prognostic parameters, incorporating new genetic and proteomic discoveries and advances in imaging, are highlighted. In addition, the roles of the tumor microenvironment, host immunity, and resistance mutations, and their effects on therapy, are discussed. An improved understanding of high-risk disease, tumor heterogeneity, and clonal evolution will guide future therapies and may ultimately lead towards a cure for MM.
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Affiliation(s)
- Christian M Schürch
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA, USA
| | - Leo Rasche
- Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Leonie Frauenfeld
- Institute of Pathology and Neuropathology and Comprehensive Cancer Center, University Hospital Tübingen, Tübingen, Germany
| | - Niels Weinhold
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Falko Fend
- Institute of Pathology and Neuropathology and Comprehensive Cancer Center, University Hospital Tübingen, Tübingen, Germany.
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16
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Wang H, Lin P. Flow Cytometric Immunophenotypic Analysis in the Diagnosis and Prognostication of Plasma Cell Neoplasms. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 96:338-350. [DOI: 10.1002/cyto.b.21844] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Hao‐Wei Wang
- Flow Cytometry and Hematopathology Section, Laboratory of PathologyCCR, NCI, NIH Bethesda Maryland 20892
| | - Pei Lin
- Department of HematopathologyThe University of Texas MD Anderson Cancer Center Houston Texas 77030
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17
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Plasma cell proliferative index is an independent predictor of progression in smoldering multiple myeloma. Blood Adv 2019; 2:3149-3154. [PMID: 30463914 DOI: 10.1182/bloodadvances.2018024794] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/19/2018] [Indexed: 01/02/2023] Open
Abstract
The plasma cell proliferative index (PCPI), determined by a slide technique or by flow cytometry, detects cells in the S phase of the cell cycle and is a useful prognostic tool in patients with plasma cell disorders such as multiple myeloma and amyloidosis. We conducted a retrospective review analyzing the prognostic effect of PCPI in 306 patients with smoldering multiple myeloma (SMM). Seventy-nine (26%) patients had an elevated PCPI (>0.5). An elevated PCPI predicted an inferior time to progression (median, 3.0 vs 7.1 years for those with a low PCPI; P = .0004). Within 24 months, the progression rate was significantly higher for patients with an elevated PCPI (49% vs. 20%; P < .0001). PCPI is a valuable tool in risk stratifying patients with SMM and identifies patients with earlier progression who may benefit from closer follow-up and consideration of early intervention trials.
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18
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Hernández JÁ, Martínez-López J, Lahuerta JJ. Timing treatment for smoldering myeloma: is earlier better? Expert Rev Hematol 2019; 12:345-354. [PMID: 30907176 DOI: 10.1080/17474086.2019.1599281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION In 2014, the International Myeloma Working Group determined that patients with ultra-high-risk smoldering multiple myeloma (SMM) should be considered for treatment as per patients with symptomatic multiple myeloma (MM), despite not having CRAB (hyperCalcemia, Renal insufficiency, Anemia, Bone disease) symptoms. Current research is elucidating whether patients with high-risk, and even intermediate-risk, SMM could benefit from early therapeutic strategies aimed at delaying progression to active MM and prolonging survival. Areas covered: The authors conducted a systematic literature search using PubMed to identify a series of patients with SMM in which prognostic and predictive factors for progression were investigated, plus the main clinical trials in SMM. Additionally, a search of active clinical trials in SMM was conducted at ClinicalTrials.gov. Expert opinion: Patients with high-risk SMM can benefit from active treatment strategies, which may prolong survival and, perhaps, provide a possible path to cure. Enabled by the limited toxicity of new drugs investigated in MM, this approach, together with consolidation with autologous transplantation, is under investigation by American and European groups. In patients with high-risk SMM who are not candidates for transplantation, combinations of oral drugs may prolong time to progression. In the near future, these approaches may be endorsed by results of ongoing clinical trials.
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Affiliation(s)
- José-Ángel Hernández
- a Hematology Department , Hospital Universitario Infanta Leonor , Madrid , Spain.,b School of Medicine , Complutense University , Madrid , Spain
| | - Joaquín Martínez-López
- b School of Medicine , Complutense University , Madrid , Spain.,c Hematology Department , Hospital Universitario 12 de Octubre , Madrid , Spain
| | - Juan-José Lahuerta
- b School of Medicine , Complutense University , Madrid , Spain.,c Hematology Department , Hospital Universitario 12 de Octubre , Madrid , Spain
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19
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González-Calle V, Mateos MV. Monoclonal gammopathies of unknown significance and smoldering myeloma: Assessment and management of the elderly patients. Eur J Intern Med 2018; 58:57-63. [PMID: 29907380 DOI: 10.1016/j.ejim.2018.05.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 05/09/2018] [Accepted: 05/23/2018] [Indexed: 11/16/2022]
Abstract
Monoclonal gammopathy of unknown significance (MGUS) is the most frequent plasma cell disorder that commonly affects elderly patients. Although it is an asymptomatic condition, as well as smoldering myeloma (SMM), the risk of progression to multiple myeloma requiring therapy or other B-cell disorders varies greatly for individual patients, remaining low for MGUS (1% per year), while higher and not uniform for SMM patients (10% per year). This scenario implies some special considerations regarding assessment and follow-up, especially in the elderly. In this review, we provide the updated diagnostic criteria of monoclonal gammopathies proposed by the International Myeloma Working Group (IMGW); the current recommendations for the assessment of asymptomatic plasma cell disorders, with some concerns about the need of geriatric evaluation in the elderly population, the importance of distinguishing myeloma-related symptomatology from signs or symptoms caused by multiple chronic conditions typically found in the elderly. Finally, the identification of predictor markers of progression has enabled a proposal of risk-adapted follow-up strategies in MGUS and SMM that should be implemented in clinical practice. Although the standard of care is observation for MGUS and SMM patients as well, a recent randomized trial targeting high-risk SMM showed the clinical benefit of early intervention. The change of the treatment paradigm is also very promising and feasible for elderly patients, as long as a comprehensive geriatric assessment is conducted to optimize early treatment and reach maximum benefit with minimum toxicity, in other words, to ensure a better quality of life for these patients.
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Affiliation(s)
- Verónica González-Calle
- Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
| | - María Victoria Mateos
- Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
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20
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Tarín F, López-Castaño F, García-Hernández C, Beneit P, Sarmiento H, Manresa P, Alda O, Villarrubia B, Blanes M, Bernabéu J, Amorós C, Sánchez-Sánchez S, Fernández-Miñano C, De Paz F, Verdú-Belmar J, Marco P, Matutes E. Multiparameter Flow Cytometry Identification of Neoplastic Subclones: A New Biomarker in Monoclonal Gammopathy of Undetermined Significance and Multiple Myeloma. Acta Haematol 2018; 141:1-6. [PMID: 30428459 DOI: 10.1159/000493568] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/07/2018] [Indexed: 01/01/2023]
Abstract
Multiparameter flow cytometry (MFC)-based clonality assessment is a powerful method of diagnosis and follow-up in monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM). However, the relevance of intraclonal heterogeneity in immunophenotypic studies remains poorly understood. The main objective of this work was to characterize the different immunophenotypic subclones in MGUS and MM patients and to investigate their correlation with disease stages. An 8-color MFC protocol with 17 markers was used to identify the subclones within the neoplastic compartment of 56 MGUS subjects, 151 newly diagnosed MM patients, 30 MM subjects in complete remission with detectable minimal residual disease, and 36 relapsed/refractory MM patients. Two or more clusters were observed in > 85% of MGUS subjects, 75% of stage I MM patients, and < 15% in stage III. Likewise, a significant correlation between the dominant subclone size, secondary cytogenetic features, and changes in the expression of CD27, CD44, and CD81 was detected. The loss of intraclonal equilibrium may be an important factor related with kinetics and risk of progression not well considered to date in MFC studies. The MFC strategy used in this work can provide useful biomarkers in MGUS and MM.
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Affiliation(s)
- Fabián Tarín
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain,
| | | | | | - Paola Beneit
- Department of Hematology, Hospital Universitario San Juan de Alicante, San Juan de Alicante, Spain
| | - Héctor Sarmiento
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Pablo Manresa
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Olga Alda
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Blanca Villarrubia
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Margarita Blanes
- Department of Hematology, Hospital General Universitario Virgen de la Salud, Elda, Spain
| | - Javier Bernabéu
- Department of Hematology, Hospital General Universitario Virgen de la Salud, Elda, Spain
| | - Carmen Amorós
- Department of Hematology, Hospital Virgen de los Lirios, Alcoy, Spain
| | | | | | - Francisco De Paz
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - José Verdú-Belmar
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Pascual Marco
- Department of Hematology, Hospital General Universitario de Alicante, Alicante, Spain
| | - Estella Matutes
- Department of Hematology, Hospital Clinic de Barcelona, Barcelona, Spain
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21
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van Nieuwenhuijzen N, Spaan I, Raymakers R, Peperzak V. From MGUS to Multiple Myeloma, a Paradigm for Clonal Evolution of Premalignant Cells. Cancer Res 2018; 78:2449-2456. [PMID: 29703720 DOI: 10.1158/0008-5472.can-17-3115] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/16/2018] [Accepted: 03/16/2018] [Indexed: 11/16/2022]
Abstract
Multiple myeloma (MM) is a treatable, but incurable, malignancy of plasma cells (PC) in the bone marrow (BM). It represents the final stage in a continuum of PC dyscrasias and is consistently preceded by a premalignant phase termed monoclonal gammopathy of undetermined significance (MGUS). The existence of this well-defined premalignant phase provides the opportunity to study clonal evolution of a premalignant condition into overt cancer. Unraveling the mechanisms of malignant transformation of PC could enable early identification of MGUS patients at high risk of progression and may point to novel therapeutic targets, thereby possibly delaying or preventing malignant transformation. The MGUS-to-MM progression requires multiple genomic events and the establishment of a permissive BM microenvironment, although it is generally not clear if the various microenvironmental events are causes or consequences of disease progression. Advances in gene-sequencing techniques and the use of serial paired analyses have allowed for a more specific identification of driver lesions. The challenge in cancer biology is to identify and target those lesions that confer selective advantage and thereby drive evolution of a premalignant clone. Here, we review recent advances in the understanding of malignant transformation of MGUS to MM. Cancer Res; 78(10); 2449-56. ©2018 AACR.
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Affiliation(s)
- Niels van Nieuwenhuijzen
- Laboratory of Translational Immunology, University Medical Center, Utrecht, the Netherlands.,Department of Hematology, University Medical Center, Utrecht, the Netherlands
| | - Ingrid Spaan
- Laboratory of Translational Immunology, University Medical Center, Utrecht, the Netherlands
| | - Reinier Raymakers
- Department of Hematology, University Medical Center, Utrecht, the Netherlands
| | - Victor Peperzak
- Laboratory of Translational Immunology, University Medical Center, Utrecht, the Netherlands.
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22
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Blum A, Bazou D, O'Gorman P. Smoldering multiple myeloma: prevalence and current evidence guiding treatment decisions. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2018; 8:21-31. [PMID: 31360091 PMCID: PMC6467346 DOI: 10.2147/blctt.s136447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell proliferative disorder associated with risk of progression to symptomatic multiple myeloma (MM) or amyloidosis. In comparison to monoclonal gammopathy of undetermined significance (MGUS), SMM has a much higher risk of progression to MM. Thanks to advances in our understanding of the risk factors, the subset of patients with ultra-high risk of progression to MM (80%-90% at 2 years) has been identified. The revision of the diagnostic criteria resulted in changes in the management of this cohort of patients. In contrast to the management guidelines for MGUS patients, SMM patients need to be studied more intensively in order to identify biomarkers necessary for accurate risk stratification. In this review, we focus on the risk of progression from SMM to MM, as well as the influence of early treatment on overall survival, time to progression and quality of life.
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Affiliation(s)
- Agnieszka Blum
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, UK,
| | - Despina Bazou
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, UK,
| | - Peter O'Gorman
- Department of Hematology, Mater Misericordiae University Hospital, Dublin, UK,
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23
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Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression. Leukemia 2018; 32:1427-1434. [DOI: 10.1038/s41375-018-0013-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/23/2017] [Accepted: 12/13/2017] [Indexed: 12/29/2022]
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24
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Gupta S, Karandikar NJ, Ginader T, Bellizzi AM, Holman CJ. Flow cytometric aberrancies in plasma cell myeloma and MGUS - correlation with laboratory parameters. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 94:500-508. [PMID: 29316245 DOI: 10.1002/cyto.b.21624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 12/11/2017] [Accepted: 01/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Multiparametric flow cytometry is a useful tool for diagnosis of plasma cell (PC) dyscrasias and assessment of minimal residual disease in plasma cell myeloma (PCM). However, the immunophenotypic differences between the clonal PCs of PCM and those of monoclonal gammopathy of undetermined significance (MGUS) as well as the correlation of these flow cytometric markers with pertinent laboratory parameters have not been evaluated. METHODS We retrospectively identified all newly diagnosed treatment-naive PCM and MGUS patients between 09/2014 and 06/2015 who underwent 10-color flow-cytometric evaluation: CD45, CD38, CD138, cKappa, cLambda, CD19, CD27, CD28, CD56, CD117. FACSDiva analysis was used to identify antigenic aberrancies and associations with pertinent laboratory parameters were evaluated. RESULTS All cases demonstrated at least two aberrancies. There was a trend toward a greater number of aberrancies in PCM, with 68% showing >/= 4 aberrancies compared with 44% in MGUS (P = 0.11). The only marker more frequently aberrant in one disease class was CD19, aberrant in 68% of PCM and 25% of MGUS (P < 0.01). In PCM, significant associations were found for CD56 non-aberrancy (P = 0.05) and the presence of amyloid and CD27 aberrancy and normal serum albumin (P = 0.05). In MGUS, CD117 expression was associated with normal hemoglobin (P = 0.03). CONCLUSIONS The PCs of PCM show a trend toward more antigenic aberrancy than those of MGUS. There is significant association between the antigenic profiles of PCM/MGUS and clinical parameters including amyloidosis, albumin level, and hemoglobin. © 2018 International Clinical Cytometry Society.
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Affiliation(s)
- Sarika Gupta
- Department of Pathology, University of Iowa, Iowa City, Iowa
| | | | - Timothy Ginader
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, Iowa
| | | | - Carol J Holman
- Department of Pathology, University of Iowa, Iowa City, Iowa
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25
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Plasma Cell Immunophenotyping Improve Prognostic Stratification of Multiple Myeloma Patients. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2018. [DOI: 10.5812/ijcm.5350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Hansford BG, Silbermann R. Advanced Imaging of Multiple Myeloma Bone Disease. Front Endocrinol (Lausanne) 2018; 9:436. [PMID: 30131767 PMCID: PMC6090033 DOI: 10.3389/fendo.2018.00436] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/16/2018] [Indexed: 12/13/2022] Open
Abstract
Multiple myeloma (MM), a malignancy of mature plasma cells, is the second most common hematologic malignancy and the most frequent cancer to involve the skeleton (1, 2). Bone disease in MM patients is characterized by lytic bone lesions that can result in pathologic fractures and severe pain. While recent advances in MM therapy have significantly increased the median survival of newly diagnosed patients (3), skeletal lesions and their sequelae continue to be a major source of patient morbidity and mortality and bone pain is the most frequent presenting symptom of MM patients (4). Rapid improvements in imaging technology now allow physicians to identify ever smaller skeletal and bone marrow abnormalities, however the clinical value of subtle radiographic findings is not always clear. This review summarizes currently available technologies for assessing MM bone disease and provides guidance for how to choose between imaging modalities.
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Affiliation(s)
- Barry G. Hansford
- Department of Diagnostic Radiology, Oregon Health and Sciences University, Portland, OR, United States
| | - Rebecca Silbermann
- Division of Hematology and Medical Oncology, Oregon Health and Sciences University, Knight Cancer Institute, Portland, OR, United States
- *Correspondence: Rebecca Silbermann
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27
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Jelinek T, Bezdekova R, Zatopkova M, Burgos L, Simicek M, Sevcikova T, Paiva B, Hajek R. Current applications of multiparameter flow cytometry in plasma cell disorders. Blood Cancer J 2017; 7:e617. [PMID: 29053157 PMCID: PMC5678219 DOI: 10.1038/bcj.2017.90] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/30/2017] [Accepted: 08/07/2017] [Indexed: 12/12/2022] Open
Abstract
Multiparameter flow cytometry (MFC) has become standard in the management of patients with plasma cell (PC) dyscrasias, and could be considered mandatory in specific areas of routine clinical practice. It plays a significant role during the differential diagnostic work-up because of its fast and conclusive readout of PC clonality, and simultaneously provides prognostic information in most monoclonal gammopathies. Recent advances in the treatment and outcomes of multiple myeloma led to the implementation of new response criteria, including minimal residual disease (MRD) status as one of the most relevant clinical endpoints with the potential to act as surrogate for survival. Recent technical progress led to the development of next-generation flow (NGF) cytometry that represents a validated, highly sensitive, cost-effective and widely available technique for standardized MRD evaluation, which also could be used for the detection of circulating tumor cells. Here we review current applications of MFC and NGF in most PC disorders including the less frequent solitary plasmocytoma, light-chain amyloidosis or Waldenström macroglobulinemia.
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Affiliation(s)
- T Jelinek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic.,Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Bezdekova
- Department of Clinical Haematology, University Hospital Brno, Brno, Czech Republic
| | - M Zatopkova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - L Burgos
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - M Simicek
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - T Sevcikova
- Faculty of Science, University of Ostrava, Ostrava, Czech Republic
| | - B Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), IDISNA, Pamplona, Spain
| | - R Hajek
- Department of Haematooncology, University Hospital Ostrava and Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Faculty of Science, University of Ostrava, Ostrava, Czech Republic
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28
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Abstract
The outcomes for the majority of patients with myeloma have improved over recent decades, driven by treatment advances. However, there is a subset of patients considered to have high-risk disease who have not benefited. Understanding how high-risk disease evolves from more therapeutically tractable stages is crucial if we are to improve outcomes. This can be accomplished by identifying the genetic mechanisms and mutations driving the transition of a normal plasma cell to one with the features of the following disease stages: monoclonal gammopathy of undetermined significance, smouldering myeloma, myeloma and plasma cell leukaemia. Although myeloma initiating events are clonal, subsequent driver lesions often occur in a subclone of cells, facilitating progression by Darwinian selection processes. Understanding the co-evolution of the clones within their microenvironment will be crucial for therapeutically manipulating the process. The end stage of progression is the generation of a state associated with treatment resistance, increased proliferation, evasion of apoptosis and an ability to grow independently of the bone marrow microenvironment. In this Review, we discuss these end-stage high-risk disease states and how new information is improving our understanding of their evolutionary trajectories, how they may be diagnosed and the biological behaviour that must be addressed if they are to be treated effectively.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, 15 Cotswold Road, Sutton SM2 5NG, UK
| | - Gareth J Morgan
- The Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA
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29
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Mateos MV, González-Calle V. Smoldering Multiple Myeloma: Who and When to Treat. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:716-722. [PMID: 28709797 DOI: 10.1016/j.clml.2017.06.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/08/2017] [Indexed: 12/01/2022]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell disorder characterized by the presence of ≥ 3 g/dL serum M-protein and/or 10% to 60% bone marrow plasma cell infiltration with no myeloma-defining event. The risk of progression to active multiple myeloma (MM) is not uniform, and several markers are useful for identifying patients at high risk of progression. The definition of the disease has recently been revisited and asymptomatic MMs at 80% to 90% of progression risk at 2 years are now considered to be active MM candidates for treatment. In the future, more precise biomarkers are necessary for accurate risk stratification to plan an optimized follow-up according to the risk of progression, as well as to expand the group of patients that can obtain a benefit if they receive early treatment. A phase 3, randomized trial in high-risk patients with SMM comparing early treatment versus observation has shown a significant benefit in terms of time to progression and overall survival for early intervention and confirmatory clinical trials will definitively contribute to establish the early treatment as standard of care in high-risk SMM.
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Affiliation(s)
- María-Victoria Mateos
- Hematology Department, Complejo Asistencial Universitario de Salamanca/Instituto Biosanitario de Salamanca (CAUSA/IBSAL), Salamanca, Spain.
| | - Verónica González-Calle
- Hematology Department, Complejo Asistencial Universitario de Salamanca/Instituto Biosanitario de Salamanca (CAUSA/IBSAL), Salamanca, Spain
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30
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Ravi P, Kumar S, Gonsalves W, Buadi F, Lacy MQ, Go RS, Dispenzieri A, Kapoor P, Lust JA, Dingli D, Lin Y, Russell SJ, Leung N, Gertz MA, Kyle RA, Bergsagel PL, Rajkumar SV. Changes in uninvolved immunoglobulins during induction therapy for newly diagnosed multiple myeloma. Blood Cancer J 2017. [PMID: 28622306 PMCID: PMC5584483 DOI: 10.1038/bcj.2017.46] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Little is known about the impact of multiple myeloma (MM) treatment on uninvolved immunoglobulins (Ig). We identified 448 patients who received high-dose dexamethasone (HD-DEX), lenalidomide and dexamethasone (RD), bortezomib and dexamethasone (VD), bortezomib, cyclophosphamide and dexamethasone (VCD) or bortezomib, lenalidomide and dexamethasone (VRD) for newly diagnosed MM at our institution between 2000 and 2013, and who had available data on absolute lymphocyte count (ALC) and quantitative uninvolved Ig at baseline and at the end of four cycles of therapy. Changes in ALC and uninvolved Ig were significantly different across treatments, with VCD and HD-DEX producing reductions in uninvolved Ig, and RD, VD and VRD leading to increases in uninvolved Ig. In addition, treatment with RD, VD and VRD was independently associated with higher odds of achieving a ⩾25% increase in or normalization of the primary uninvolved Ig on multivariate analysis. Although achievement of a humoral response in the primary uninvolved Ig was associated with a higher odds of achieving VGPR or better after four cycles of therapy, it was not associated with improved overall survival. These data highlight the different mechanisms of action of MM drugs and point toward a possible role for the use of VCD in treating antibody-mediated autoimmune disease.
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Affiliation(s)
- P Ravi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - S Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - W Gonsalves
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - F Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R S Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - J A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - D Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Y Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S J Russell
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - N Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P L Bergsagel
- Division of Hematology and Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - S V Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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31
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Mateos MV, Bladé J, Lahuerta JJ, San-Miguel J. Tratamiento del mieloma múltiple asintomático: recomendaciones del Grupo Español de Mieloma. Med Clin (Barc) 2017; 148:517-523. [DOI: 10.1016/j.medcli.2017.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/15/2017] [Indexed: 10/19/2022]
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32
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Mikulasova A, Wardell CP, Murison A, Boyle EM, Jackson GH, Smetana J, Kufova Z, Pour L, Sandecka V, Almasi M, Vsianska P, Gregora E, Kuglik P, Hajek R, Davies FE, Morgan GJ, Walker BA. The spectrum of somatic mutations in monoclonal gammopathy of undetermined significance indicates a less complex genomic landscape than that in multiple myeloma. Haematologica 2017; 102:1617-1625. [PMID: 28550183 PMCID: PMC5685224 DOI: 10.3324/haematol.2017.163766] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 05/16/2017] [Indexed: 01/10/2023] Open
Abstract
Monoclonal gammopathy of undetermined significance is a pre-malignant precursor of multiple myeloma with a 1% risk of progression per year. Although targeted analyses have shown the presence of specific genetic abnormalities such as IGH translocations, RB1 deletion, 1q gain, hyperdiploidy or RAS gene mutations, little is known about the molecular mechanism of malignant transformation. We performed whole exome sequencing together with comparative genomic hybridization plus single nucleotide polymorphism array analysis in 33 flow-cytometry-separated abnormal plasma cell samples from patients with monoclonal gammopathy of undetermined significance to describe somatic gene mutations and chromosome changes at the genome-wide level. Non-synonymous mutations and copy-number alterations were present in 97.0% and in 60.6% of cases, respectively. Importantly, the number of somatic mutations was significantly lower in monoclonal gammopathy of undetermined significance than in myeloma (P<10-4) and we identified six genes that were significantly mutated in myeloma (KRAS, NRAS, DIS3, HIST1H1E, EGR1 and LTB) within the monoclonal gammopathy of undetermined significance dataset. We also found a positive correlation with increasing chromosome changes and somatic gene mutations. IGH translocations, comprising t(4;14), t(11;14), t(14;16) and t(14;20), were present in 27.3% of cases and in a similar frequency to myeloma, consistent with the primary lesion hypothesis. MYC translocations and TP53 deletions or mutations were not detected in samples from patients with monoclonal gammopathy of undetermined significance, indicating that they may be drivers of progression to myeloma. Data from this study show that monoclonal gammopathy of undetermined significance is genetically similar to myeloma, however overall genetic abnormalities are present at significantly lower levels in monoclonal gammopathy of undetermined significant than in myeloma.
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Affiliation(s)
- Aneta Mikulasova
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Christopher P Wardell
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Alexander Murison
- Center for Myeloma Research, Division of Molecular Pathology, Institute of Cancer Research, London, UK
| | - Eileen M Boyle
- Center for Myeloma Research, Division of Molecular Pathology, Institute of Cancer Research, London, UK
| | - Graham H Jackson
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Jan Smetana
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Czech Republic
| | - Zuzana Kufova
- Faculty of Medicine, University of Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Czech Republic
| | - Ludek Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Czech Republic
| | - Viera Sandecka
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Czech Republic
| | - Martina Almasi
- Department of Clinical Hematology, University Hospital Brno, Czech Republic
| | - Pavla Vsianska
- Department of Clinical Hematology, University Hospital Brno, Czech Republic
| | - Evzen Gregora
- Department of Internal Medicine and Hematology, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kuglik
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Czech Republic
| | - Roman Hajek
- Faculty of Medicine, University of Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Czech Republic
| | - Faith E Davies
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brian A Walker
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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33
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Genadieva Stavric S, Bonello F, Bringhen S, Boccadoro M, Larocca A. How is patient care for multiple myeloma advancing? Expert Rev Hematol 2017; 10:551-561. [DOI: 10.1080/17474086.2017.1326814] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Francesca Bonello
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Sara Bringhen
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, University of Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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34
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Sandecká V, Hájek R, Pour L, Špička I, Ščudla V, Gregora E, Radocha J, Walterová L, Kessler P, Zahradová L, Adamová D, Valentova K, Vonke I, Obernauerová J, Starostka D, Wróbel M, Brožová L, Jarkovský J, Mikulášová A, Říhová L, Ševčíková S, Straub J, Minařík J, Adam Z, Krejčí M, Král Z, Maisnar V. A first Czech analysis of 1887 cases with monoclonal gammopathy of undetermined significance. Eur J Haematol 2017; 99:80-90. [PMID: 28384387 DOI: 10.1111/ejh.12894] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant condition with a risk of malignant conversion. PATIENTS AND METHODS With the aim to estimate the cumulative risk MGUS progression to hematologic malignancies, we analyzed a nationwide population-based cohort of 1887 MGUS patients from the Czech Registry of Monoclonal Gammopathies (RMG) between 2007 and 2013. RESULTS During the follow-up period (median 4 years; range 0.6-34.8), progression to hematologic malignancies was observed in 8.6% (162 of 1887) of patients. Factors associated with progression were as follows: M-protein concentration ≥1.5 g/dL, pathological sFLC (<0.26 or >1.65) ratio, bone marrow plasma cells (BMPCs) in cytology >5%, immunoparesis, age ≥69 years, and the level of serum hemoglobin at baseline <12.0 g/dL. Combining these factors, we propose a new risk model (CMG model). The risk of progression at 10 years was 1.6%, 16.9%, 22.9%, 39.4%, and 52.3%, respectively, if 0 (reference group), one, two, three, or four to five risk factors are present (P<.001) with HR 63 times higher compared to the reference MGUS group. CONCLUSION The new CMG model was established with an advantage for better identification of MGUS patients at low risk.
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Affiliation(s)
- Viera Sandecká
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Roman Hájek
- Department of Clinical Hematology, University Hospital, Ostrava, Czech Republic.,Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Luděk Pour
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Ivan Špička
- Department of Internal Medicine, University Hospital, Praha, Czech Republic
| | - Vlastimil Ščudla
- Department of Hemato-Oncology, University Hospital, Olomouc, Czech Republic
| | - Evžen Gregora
- Department of Clinical Hematology, University Hospital Kralovske Vinohrady, Praha, Czech Republic
| | - Jakub Radocha
- Department of Medicine - Hematology, University Hospital, Hradec Kralove, Czech Republic
| | - Lenka Walterová
- Department of Clinical Hematology, Hospital Liberec, Czech Republic
| | - Petr Kessler
- Department of Hematology and Transfusion Medicine, Hospital Pelhřimov, Czech Republic
| | - Lenka Zahradová
- Department of Clinical Hematology, University Hospital, Ostrava, Czech Republic
| | - Dagmar Adamová
- Department of Hematology and Transfusion, Hospital Opava, Czech Republic
| | - Kamila Valentova
- Department of Clinical Hematology, Thomayer Hospital, Praha, Czech Republic
| | - Ivan Vonke
- Department of Clinical Hematology, Hospital České Budejovice, Czech Republic
| | - Jarmila Obernauerová
- Department of Hematology and Transfusion, Hospital Mlada Boleslav, Czech Republic
| | - David Starostka
- Department of Clinical Hematology, Hospital Havířov, Czech Republic
| | - Marek Wróbel
- Department of Clinical Hematology, Hospital Nový Jičín, Czech Republic
| | - Lucie Brožová
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jiří Jarkovský
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Aneta Mikulášová
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Laboratory of Molecular Cytogenetics, Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Lucie Říhová
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Sabina Ševčíková
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Ján Straub
- Department of Internal Medicine, University Hospital, Praha, Czech Republic
| | - Jiří Minařík
- Department of Hemato-Oncology, University Hospital, Olomouc, Czech Republic
| | - Zdeněk Adam
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Marta Krejčí
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Zdeněk Král
- Department of Internal Medicine, Hematology and Oncology, University Hospital, Brno, Czech Republic
| | - Vladimír Maisnar
- Department of Medicine - Hematology, University Hospital, Hradec Kralove, Czech Republic
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35
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Abstract
This article provides an overview of the role of flow cytometry in the diagnosis and follow-up of plasma cell myeloma. A brief introduction to the general immunophenotypic features of normal and myeloma plasma cells is provided, followed by a discussion of technical issues as they relate to the application of flow cytometry in this entity. The prognostic and therapeutic utility of flow cytometric immunophenotyping in myeloma is also analyzed, with an emphasis on the growing role of minimal residual analysis as potential biomarker for evaluating treatment efficacy and for tailoring risk-adapted treatment, in prospective clinical trials.
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Affiliation(s)
- Horatiu Olteanu
- Department of Pathology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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36
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Maciocia N, Wechalekar A, Yong K. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma (SMM): a practical guide to management. Hematol Oncol 2016; 35:432-439. [DOI: 10.1002/hon.2345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/08/2016] [Accepted: 08/01/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Nicola Maciocia
- Department of Haematology; University College London Hospitals; London UK
| | - Ashutosh Wechalekar
- Department of Haematology; University College London Hospitals; London UK
- National Amyloidosis Centre; University College London; London UK
| | - Kwee Yong
- Department of Haematology, Cancer Institute; University College London; London UK
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37
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Ravi P, Kumar S, Larsen JT, Gonsalves W, Buadi F, Lacy MQ, Go R, Dispenzieri A, Kapoor P, Lust JA, Dingli D, Lin Y, Russell SJ, Leung N, Gertz MA, Kyle RA, Bergsagel PL, Rajkumar SV. Evolving changes in disease biomarkers and risk of early progression in smoldering multiple myeloma. Blood Cancer J 2016; 6:e454. [PMID: 27471870 PMCID: PMC5030386 DOI: 10.1038/bcj.2016.65] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 06/23/2016] [Indexed: 01/07/2023] Open
Abstract
We studied 190 patients with smoldering multiple myeloma (SMM) at our institution between 1973 and 2014. Evolving change in monoclonal protein level (eMP) was defined as ⩾10% increase in serum monoclonal protein (M) and/or immunoglobulin (Ig) (M/Ig) within the first 6 months of diagnosis (only if M-protein ⩾3 g/dl) and/or ⩾25% increase in M/Ig within the first 12 months, with a minimum required increase of 0.5 g/dl in M-protein and/or 500 mg/dl in Ig. Evolving change in hemoglobin (eHb) was defined as ⩾0.5 g/dl decrease within 12 months of diagnosis. A total of 134 patients (70.5%) progressed to MM over a median follow-up of 10.4 years. On multivariable analysis adjusting for factors known to predict for progression to MM, bone marrow plasma cells ⩾20% (odds ratio (OR)=3.37 (1.30-8.77), P=0.013), eMP (OR=8.20 (3.19-21.05), P<0.001) and eHb (OR=5.86 (2.12-16.21), P=0.001) were independent predictors of progression within 2 years of SMM diagnosis. A risk model comprising these variables was constructed, with median time to progression of 12.3, 5.1, 2.0 and 1.0 years among patients with 0-3 risk factors respectively. The 2-year progression risk was 81.5% in individuals who demonstrated both eMP and eHb, and 90.5% in those with all three risk factors.
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Affiliation(s)
- P Ravi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - S Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - J T Larsen
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - W Gonsalves
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - F Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - J A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - D Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Y Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S J Russell
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - N Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P L Bergsagel
- Division of Hematology and Oncology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - S V Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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38
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Mikulasova A, Smetana J, Wayhelova M, Janyskova H, Sandecka V, Kufova Z, Almasi M, Jarkovsky J, Gregora E, Kessler P, Wrobel M, Walker BA, Wardell CP, Morgan GJ, Hajek R, Kuglik P. Genomewide profiling of copy-number alteration in monoclonal gammopathy of undetermined significance. Eur J Haematol 2016; 97:568-575. [PMID: 27157252 DOI: 10.1111/ejh.12774] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2016] [Indexed: 12/23/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a benign condition with an approximate 1% annual risk of symptomatic plasma cell disorder development, mostly to multiple myeloma (MM). We performed genomewide screening of copy-number alterations (CNAs) in 90 MGUS and 33 MM patients using high-density DNA microarrays. We identified CNAs in a smaller proportion of MGUS (65.6%) than in MM (100.0%, P = 1.31 × 10-5 ) and showed median number of CNAs is lower in MGUS (3, range 0-22) than in MM (13, range 4-38, P = 1.82 × 10-10 ). In the MGUS cohort, the most frequent losses were located at 1p (5.6%), 6q (6.7%), 13q (30.0%), 14q (14.4%), 16q (8.9%), 21q (5.6%), and gains at 1q (23.3%), 2p (6.7%), 6p (13.3%), and Xq (7.8%). Hyperdiploidy was detected in 38.9% of MGUS cases, and the most frequent whole chromosome gains were 3 (25.6%), 5 (23.3%), 9 (37.8%), 15 (23.3%), and 19 (32.2%). We also identified CNAs such as 1p, 6q, 8p, 12p, 13q, 16q losses, 1q gain and hypodiploidy, which are potentially associated with an adverse prognosis in MGUS. In summary, we showed that MGUS is similar to MM in that it is a genetically heterogeneous disorder, but overall cytogenetic instability is lower than in MM, which confirms that genetic abnormalities play important role in monoclonal gammopathies.
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Affiliation(s)
- Aneta Mikulasova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jan Smetana
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic
| | - Marketa Wayhelova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic
| | - Helena Janyskova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Viera Sandecka
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Zuzana Kufova
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Martina Almasi
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Evzen Gregora
- Department of Internal Medicine and Hematology, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kessler
- Department of Hematology and Transfusion, General Hospital, Pelhrimov, Czech Republic
| | - Marek Wrobel
- Department of Oncology, Hospital Novy Jicin, Novy Jicin, Czech Republic
| | - Brian A Walker
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Christopher P Wardell
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Laboratory for Genome Sequencing Analysis, RIKEN Center for Integrative Medical Sciences, Tokyo, Japan
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Roman Hajek
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Petr Kuglik
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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39
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van de Donk NWCJ, Mutis T, Poddighe PJ, Lokhorst HM, Zweegman S. Diagnosis, risk stratification and management of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. Int J Lab Hematol 2016; 38 Suppl 1:110-22. [DOI: 10.1111/ijlh.12504] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2016] [Indexed: 11/28/2022]
Affiliation(s)
| | - T. Mutis
- Department of Hematology; VU University Medical Center; Amsterdam The Netherlands
| | - P. J. Poddighe
- Department of Clinical Genetics; VU University Medical Center; Amsterdam The Netherlands
| | - H. M. Lokhorst
- Department of Hematology; VU University Medical Center; Amsterdam The Netherlands
| | - S. Zweegman
- Department of Hematology; VU University Medical Center; Amsterdam The Netherlands
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40
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Ludwig H, Milosavljevic D, Berlanga O, Zojer N, Hübl W, Fritz V, Harding S. Suppression of the noninvolved pair of the myeloma isotype correlates with poor survival in newly diagnosed and relapsed/refractory patients with myeloma. Am J Hematol 2016; 91:295-301. [PMID: 26662888 PMCID: PMC4832268 DOI: 10.1002/ajh.24268] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 01/09/2023]
Abstract
Heavy light chain (HLC) assays allow precise measurement of the monoclonal and of the noninvolved polyclonal immunoglobulins of the same isotype as the M‐protein (e.g., monoclonal IgAκ and polyclonal IgAλ in case of an IgAκ myeloma), which was not possible before. The noninvolved polyclonal immunoglobulin is termed ‘HLC‐matched pair’. We investigated the impact of the suppression of the HLC‐matched pair on outcome in 203 patients with multiple myeloma, a phenomenon that likely reflects the host's attempt to control the myeloma clone. Severe (>50%) HLC‐matched pair suppression was identified in 54.5% of the 156 newly diagnosed patients and was associated with significantly shorter survival (45.4 vs. 71.9 months, P = 0.019). This correlation was statistically significant in IgG patients (46.4 vs. 105.1 months, P = 0.017), but not in patients with IgA myelomas (32.9 vs. 54.1 months, P = 0.498). At best response, HLC‐matched pair suppression improved only in patients with ≥VGPR, indicating partial or complete humoral immune reconstitution during remission in those with excellent response. Severe HLC‐matched pair suppression retained its prognostic impact also during follow‐up after first response. In the 47 pretreated patients with relapsed/refractory disease, a similar correlation between severe HLC suppression and survival was noted (22.8 vs. not reached, P = 0.028). Suppression of the polyclonal immunoglobulins of the other isotypes than the myeloma protein correlated neither with HLC‐matched pair suppression, nor with outcome. Multivariate analysis identified severe HLC‐matched pair suppression as independent risk factor for shorter survival, highlighting the impact of isotype specific immune dysregulation on outcome in multiple myeloma. Am. J. Hematol. 91:295–301, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Heinz Ludwig
- Wilhelminen Cancer Research Institute, C/O Department of Medicine ICenter of Oncology, Hematology with Outpatient Department and Palliative Care, WilheminenhospitalVienna Austria
| | | | | | - Niklas Zojer
- Department of Medicine ICenter of Oncology, Hematology with Outpatient Department and Palliative Care, WilheminenhospitalVienna Austria
| | - Wolfgang Hübl
- Department of Laboratory MedicineWilhelminenhospitalVienna Austria
| | - Veronique Fritz
- Wilhelminen Cancer Research Institute, C/O Department of Medicine ICenter of Oncology, Hematology with Outpatient Department and Palliative Care, WilheminenhospitalVienna Austria
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41
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Abstract
Monoclonal gammopathy of undetermined significance (MHUS) is characterized by the presence of a serum M-protein less than 3 g/dL, less than 10 % clonal plasma cells in the bone marrow, and the absence of myeloma-defining event. Smoldering multiple myeloma (SMM) is an asymptomatic disorder characterized by the presence of ≥3 g/dL serum M-protein and/or 10-60 % bone marrow plasma cell infiltration with no myeloma-defining event. The risk of progression to multiple myeloma (MM) requiring therapy varies greatly for individual patients, but it is uniform and 1 % per year for MGUS, while higher (10 % per year) and not uniform for SMM patients. The definition of MM was recently revisited patients previously labeled as SMM with a very high risk of progression (80-90 % at 2 years) were included in the updated definition of MM requiring therapy. The standard of care is observation for MGUS patients and although this also applies for SMM, a recent randomized trial targeting high-risk SMM showed that early intervention was associated with better progression-free and overall survival. Biomarkers have become an integrated part of diagnostic criteria for MM requiring therapy, as well as clinical risk stratification of patients with SMM. This paper reviews and discusses clinical implications for MGUS and SMM patients.
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Affiliation(s)
- María-Victoria Mateos
- University Hospital of Salamanca/IBSAL, Paseo San Vicente, 58-182, 37007, Salamanca, Spain.
| | - Ola Landgren
- Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York, USA
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42
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Bories C, Jagannath S. Asymptomatic monoclonal gammopathies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 14 Suppl:S78-86. [PMID: 25486961 DOI: 10.1016/j.clml.2014.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 05/19/2014] [Indexed: 11/27/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) represent the earlier phases of plasma cell dyscrasias. Their definition is based on absence of end-organ damage with presence of a malignant clone that grows in the bone marrow. They share, as a common feature, the risk of progression to a symptomatic disease. MGUS progression risk is approximately 1% per year, and SMM has a risk of progression of 10% for the first 5 years which tapers off over time. The main purpose of identification of these earlier phases of the plasma cell dyscrasia was to identify patients who do not warrant treatment with chemotherapy, in whom the risk of treatment outweighs the benefit. Over the years, the definitions have not been modified to incorporate developments in imaging (magnetic resonance or positron emission and computed tomography), or genomics to identify patients at highest risk of progression within 2 years, where wait and watch might not be an appropriate option. In the absence of such definition, patients who have only a 50% chance of progression within 2 years are being offered therapy, which might also not be an optimal approach. In this review, we provide an overview of the definition, current prognostic factors, and risk stratifications in asymptomatic gammopathies, and discuss clinical trial outcomes in high-risk SMM.
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Affiliation(s)
| | - Sundar Jagannath
- Department of Hematology/Oncology, Mt Sinai Medical Center, New York, NY.
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43
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Abstract
PURPOSE OF REVIEW Smoldering multiple myeloma (SMM) is an asymptomatic plasma cell disorder characterized by the presence of one or both features of serum M-protein at least 30 g/l and bone marrow plasma cell infiltration at least 10%. The standard of care is no treatment until symptomatic progression occurs. However, the risk of progression to active multiple myeloma is not uniform, and several markers are useful for identifying SMM patients at high risk of progression to active multiple myeloma. Overall, the presence of these factors is useful to stratify SMM patients according to their risk but the forthcoming challenge is to identify high and ultra-high-risk SMM patients because they can benefit from early treatment. RECENT FINDINGS A randomized trial that focused on high-risk SMM patients allocated to receive early treatment with lenalidomide plus dexamethasone vs. observation did report a significant benefit with respect to time to progression and overall survival. SUMMARY High-risk SMM patients should be targeted for early treatment, and more such efforts should be made to identify the ultra-high-risk subgroup within the high-risk SMM patient population which may be considered as early multiple myeloma and thereby candidates for receiving therapy before they develop myeloma-related symptomatology.
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44
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45
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Smoldering multiple myeloma. BIOMED RESEARCH INTERNATIONAL 2015; 2015:623254. [PMID: 26000300 PMCID: PMC4426782 DOI: 10.1155/2015/623254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/06/2014] [Indexed: 01/24/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic precursor stage of multiple myeloma (MM) characterized by clonal bone marrow plasma cells (BMPC) ≥ 10% and/or M protein level ≥ 30 g/L in the absence of end organ damage. It represents an intermediate stage between monoclonal gammopathy of undetermined significance (MGUS) and symptomatic MM. The risk of progression to symptomatic MM is not uniform, and several parameters have been reported to predict the risk of progression. These include the level of M protein and the percentage of BMPC, the proportion of immunophenotypically aberrant plasma cells, and the presence of immunoparesis, free light-chain (FLC) ratio, peripheral blood plasma cells (PBPC), pattern of serum M protein evolution, abnormal magnetic resonance imaging (MRI), cytogenetic abnormalities, IgA isotype, and Bence Jones proteinuria. So far treatment is still not recommended for SMM, because several trials suggested that patients with SMM do not benefit from early treatment. However, the Mateos et al. trial showed a survival benefit after early treatment with lenalidomide plus dexamethasone in patients with high-risk SMM. This trial has prompted a reevaluation of early treatment in an asymptomatic patient population.
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46
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Plasma cell morphology in multiple myeloma and related disorders. Morphologie 2015; 99:38-62. [PMID: 25899140 DOI: 10.1016/j.morpho.2015.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/23/2015] [Indexed: 12/28/2022]
Abstract
Normal and reactive plasma cells (PC) are easy to ascertain on human bone marrow films, due to their small mature-appearing nucleus and large cytoplasm, the latter usually deep blue after Giemsa staining. Cytoplasm is filled with long strands of rough endoplasmic reticulum and one large Golgi apparatus (paranuclear hof), demonstrating that PC are dedicated mainly to protein synthesis and excretion (immunoglobulin). Deregulation of the genome may induce clonal expansion of one PC that will lead to immunoglobulin overproduction and eventually to one among the so-called PC neoplasms. In multiple myeloma (MM), the number of PC is over 10% in most patients studied. Changes in the morphology of myeloma PC may be inconspicuous as compared to normal PC (30-50% patients). In other instances PC show one or several morphological changes. One is related to low amount of cytoplasm, defining lymphoplasmacytoid myeloma (10-15% patients). In other cases (40-50% patients), named immature myeloma cases, nuclear-cytoplasmic asynchrony is observed: presence of one nucleolus, finely dispersed chromatin and/or irregular nuclear contour contrast with a still large and blue (mature) cytoplasm. A peculiar morphological change, corresponding to the presence of very immature PC named plasmablasts, is observed in 10-15% cases. Several prognostic morphological classifications have been published, as mature myeloma is related to favorable outcome and immature myeloma, peculiarly plasmablastic myeloma, is related to dismal prognosis. However, such classifications are no longer included in current prognostic schemes. Changes related to the nucleus are very rare in monoclonal gammopathy of unknown significance (MGUS). In contrast, anomalies related to the cytoplasm of PC, including color (flaming cells), round inclusions (Mott cells, Russell bodies), Auer rod-like or crystalline inclusions, are reported in myeloma cases as well as in MGUS and at times in reactive disorders. They do not correspond to malignant changes of PC but are related to abnormal synthesis, trafficking, or excretion of the immunoglobulin that is stored in excess within the cytoplasm. Occurrence of crystalline inclusions within PC may be the first anomaly leading to the diagnosis of adult Fanconi syndrome. After a historical perspective, the authors report on the various morphological aspects of PC that may occur in multiple myeloma and related disorders, and discuss about their clinical and pathophysiological significance. Today, morphological identification and accurate determination of % PC within bone marrow remain ancillary criteria for the diagnosis of MM and help for the diagnosis of rare renal disorders.
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47
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Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder. SMM is distinguished from monoclonal gammopathy of undetermined significance by a much higher risk of progression to multiple myeloma (MM). There have been major advances in the diagnosis, prognosis, and management of SMM in the last few years. These include a revised disease definition, identification of several new prognostic factors, a classification based on underlying cytogenetic changes, and new treatment options. Importantly, a subset of patients previously considered SMM is now reclassified as MM on the basis of biomarkers identifying patients with an ≥80% risk of progression within 2 years. SMM has assumed greater significance on the basis of recent trials showing that early therapy can be potentially beneficial to patients. As a result, there is a need to accurately diagnose and risk-stratify patients with SMM, including routine incorporation of modern imaging and laboratory techniques. In this review, we outline current concepts in diagnosis and risk stratification of SMM, and provide specific recommendations on the management of SMM.
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48
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Gentile M, Offidani M, Vigna E, Corvatta L, Recchia AG, Morabito L, Martino M, Morabito F, Gentili S. Smoldering multiple myeloma: to treat or not to treat. Expert Opin Pharmacother 2015; 16:785-90. [DOI: 10.1517/14656566.2015.1007952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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49
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Mateos MV, San Miguel JF. Smoldering multiple myeloma: when to observe and when to treat? Am Soc Clin Oncol Educ Book 2015:e484-e492. [PMID: 25993213 DOI: 10.14694/edbook_am.2015.35.e484] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Smoldering multiple myeloma (SMM) is an asymptomatic disorder characterized by the presence of at least 3 g/dL of serum M-protein and/or 10% to 60% bone marrow plasma cell infiltration with no myeloma-defining event. The risk of progression to active multiple myeloma (MM) is not uniform and several markers are useful for identifying patients at high risk of progression. The definition of the disease has recently been revisited and patients with asymptomatic MM at 80% to 90% of progression risk at 2 years are now considered to have MM. Although the current standard of care is not to treat, a randomized trial in patients with high-risk SMM that compared early treatment versus observation demonstrated that early intervention resulted in substantial benefits in terms of time to progression and overall survival (OS). These findings highlight the need to follow a correct diagnosis by an accurate risk stratification to plan an optimized follow-up according to the risk of disease progression.
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Affiliation(s)
- María-Victoria Mateos
- From the University Hospital of Salamanca/IBSAL, Salamanca, Spain; Clínica Universidad de Navarra/CIMA, Navarra, Spain
| | - Jesús-F San Miguel
- From the University Hospital of Salamanca/IBSAL, Salamanca, Spain; Clínica Universidad de Navarra/CIMA, Navarra, Spain
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50
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Mateos MV. Management of asymptomatic myeloma patients. Expert Rev Hematol 2014; 8:19-27. [PMID: 25363073 DOI: 10.1586/17474086.2015.978852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Smoldering multiple myeloma is an asymptomatic disorder characterized by the presence of ≥30 g/l serum M-protein and/or ≥10% bone marrow plasma cell infiltration. The risk of progression to active multiple myeloma is not uniform, and several markers are useful for identifying patients at high risk of this. Although the current standard of care is not to treat, a randomized trial in high-risk smoldering multiple myeloma patients comparing those allocated to receive early treatment with lenalidomide plus dexamethasone with those under observation reported a significant benefit with respect to time to progression and overall survival. We conclude that efforts should be made to identify high-risk patients who are candidates for receiving early treatment before they develop myeloma-related symptomatology.
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Affiliation(s)
- María-Victoria Mateos
- Hospital Universitario de Salamanca - Hematology, Paseo San Vicente, 58-182 Salamanca, Spain
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