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Tawfiq RK, Abeykoon JP, Kapoor P. Bruton Tyrosine Kinase Inhibition: an Effective Strategy to Manage Waldenström Macroglobulinemia. Curr Hematol Malig Rep 2024; 19:120-137. [PMID: 38536576 DOI: 10.1007/s11899-024-00731-0] [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] [Accepted: 02/26/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE OF REVIEW The treatment of Waldenström macroglobulinemia (WM) has evolved over the past decade. With the seminal discoveries of MYD88 and CXCR warts, hypogammaglobulinemia, infections, and myelokathexis (WHIM) mutations in WM cells, our understanding of the disease biology and treatment has improved. The development of a new class of agents, Bruton tyrosine kinase inhibitors (BTKi), has substantially impacted the treatment paradigm of WM. Herein, we review the current and emerging BTKi and the evidence for their use in WM. RECENT FINDINGS Clinical trials have established the role of covalent BTKi in the treatment of WM. Their efficacy is compromised among patients who harbor CXCR4WHIM mutation or MYD88WT genotype. The development of BTKC481 mutation-mediated resistance to covalent BTKi may lead to disease refractoriness. Novel, non-covalent, next-generation BTKi are emerging, and preliminary results of the early phase clinical trials show promising activity in WM, even among patients refractory to a covalent BTKi. Covalent BTK inhibitors have demonstrated meaningful outcomes in treatment-naïve (TN) and relapsed refractory (R/R) WM, particularly among those harboring the MYD88L265P mutation. The next-generation BTKi demonstrate improved selectivity, resulting in a more favorable toxicity profile. In WM, BTKi are administered until progression or the development of intolerable toxicity. Consequently, the potential for acquired resistance, the emergence of cumulative toxicities, and treatment-related financial burden are critical challenges associated with the continuous therapy approach. By circumventing BTK C481 mutations that alter the binding site to covalent BTKi, the non-covalent BTKi serve as alternative agents in the event of acquired resistance. Head-to-head comparative trials with the conventional chemoimmunotherapies are lacking. The findings of the RAINBOW trial (NCT046152), comparing the dexamethasone, rituximab, and cyclophosphamide (DRC) regimen to the first-generation, ibrutinib are awaited, but more studies are needed to draw definitive conclusions on the comparative efficacy of chemoimmunotherapy and BTKi. Complete response is elusive with BTKi, and combination regimens to improve upon the efficacy and limit the treatment duration are also under evaluation in WM.
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Affiliation(s)
- Reema K Tawfiq
- Department of Hematology-Oncology, Mayo Clinic, Jacksonville, FL, USA
| | - Jithma P Abeykoon
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Prashant Kapoor
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Pan Q, Cao X, Li J, Li F, Luo Y. Different extramedullary disease shown in chemokine receptor 4 targeted PET/CT with [68Ga]Ga-pentixafor in patients with Waldenström macroglobulinemia and smoldering disease. Nucl Med Commun 2024:00006231-990000000-00299. [PMID: 38745523 DOI: 10.1097/mnm.0000000000001862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
INTRODUCTION It is important to distinguish Waldenström macroglobulinemia from smoldering Waldenström macroglobulinemia (sWM), because only patients with Waldenström macroglobulinemia require treatment, however the distinction can be clinically complex. The aim of this study is to investigate whether [68Ga]Ga-pentixafor PET/CT shows different characteristics in sWM and Waldenström macroglobulinemia patients and therefore can help to differentiate Waldenström macroglobulinemia and sWM. RESULTS Thirty-seven patients with newly diagnosed Waldenström macroglobulinemia and 11 sWM patients were analyzed [35 men and 13 women; 64.3 ± 10.7 (range, 29-87) years old]. The SUVmax of bone marrow disease, lymph nodes, and other extramedullary diseases on [68Ga]Ga-pentixafor were significantly higher than those on 2-[18F]FDG PET/CT (P < 0.05). On [68Ga]Ga-pentixafor PET/CT, patients with Waldenström macroglobulinemia had more lymph node regions involved, significantly higher incidence of involvement in more than three lymph node regions, larger nodal disease, and higher incidence of other extramedullary disease when compared with sWM patients (P < 0.05). Waldenström macroglobulinemia patients showed significantly higher total lesions uptake, total lesion volume, and SUVmax of extramedullary disease than sWM patients did (P < 0.05). None of the visual or semiquantitative indexes in 2-[18F]FDG PET/CT showed significant difference between Waldenström macroglobulinemia and sWM patients. CONCLUSION [68Ga]Ga-pentixafor PET/CT had better diagnostic performance than 2-[18F]FDG PET/CT in Waldenström macroglobulinemia. Patients with Waldenström macroglobulinemia presented with more extensive extramedullary disease shown in [68Ga]Ga-pentixafor PET/CT than sWM patients did.
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Affiliation(s)
- Qingqing Pan
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine
| | - Xinxin Cao
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing, China
| | - Jian Li
- Department of Hematology, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing, China
| | - Fang Li
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine
| | - Yaping Luo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine
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Kapoor P, Rajkumar SV. Current approach to Waldenström macroglobulinemia. Blood Rev 2023; 62:101129. [PMID: 37659912 PMCID: PMC10841191 DOI: 10.1016/j.blre.2023.101129] [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: 07/10/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023]
Abstract
Waldenström macroglobulinemia (WM) is a unique CD20+, B-cell non-Hodgkin lymphoma, characterized by lymphoplasmacytic infiltration of the bone marrow and circulating monoclonal immunoglobulin M. The clinical manifestations and outcomes of patients are highly variable. High-level evidence supports integration of monoclonal anti-CD20 antibody, rituximab, to the chemotherapy backbone to treat WM. However, its contemporary management has become more nuanced, with deeper understanding of the pathophysiology and incorporation of Bruton's tyrosine kinase (BTK) inhibitors to the treatment paradigm. Prior knowledge of the patients' MYD88L265P and CXCR4 mutation status may aid in the treatment decision-making. Currently, the two frequently utilized approaches include fixed-duration chemoimmunotherapy and BTK inhibitor-based continuous treatment until progression. Randomized trials comparing these two vastly divergent approaches are lacking. Recent studies demonstrating efficacy of B cell lymphoma-2 (BCL2) inhibitors and non-covalent BTK inhibitors in patients, previously exposed to a covalent BTK inhibitor, are a testament to the rapidly expanding options against WM.
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Bustoros M, Gribbin C, Castillo JJ, Furman R. Biomarkers of Progression and Risk Stratification in Asymptomatic Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2023; 37:e1-e13. [PMID: 37574332 DOI: 10.1016/j.hoc.2023.06.012] [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: 08/15/2023]
Abstract
Waldenström macroglobulinemia is an indolent IgM-secreting B-cell lymphoplasmacytic lymphoma that is preceded by an asymptomatic stage. Clinical and molecular features have been used in risk models to predict progression rates in different asymptomatic subgroups. Risk models used both disease-specific and nonspecific biomarkers for asymptomatic patients. Recently, models that incorporate continuous variables rather than distinct cutoffs have emerged to more accurately predict the risk of progression. Integrating genetic alterations to the clinical models is a promising approach that could improve risk stratification and management of asymptomatic patients.
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Affiliation(s)
- Mark Bustoros
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA.
| | - Caitlin Gribbin
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard Furman
- Division of Hematology and Medical Oncology, Department of Medicine, Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, NY, USA
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Abstract
Waldenström macroglobulinemia (WM) is a rare subtype of non-Hodgkin lymphoma characterized by the presence of lymphoplasmacytic lymphoma (LPL) in the bone marrow accompanied by a monoclonal immunoglobulin type M (IgM) in the serum. WM was first described only 80 years ago and became reportable in the US as a malignancy in 1988. Very little systematic research was conducted prior to 2000 to characterize incidence, clinical characteristics, risk factors or diagnostic and prognostic criteria, and there were essentially no WM-specific clinical interventional trials. Since the inaugural meeting of the International Workshop in Waldenström's Macroglobulinemia (IWWM) in 2000, WM has become the focus of a steadily increasing and productive body of research, engaging a growing number of investigators throughout the world. This introductory overview provides summary of the current understanding of the epidemiology of WM/LPL as a backdrop for a series of consensus panel recommendations arising from research presented at the 11th IWWM.
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Affiliation(s)
- Mary L McMaster
- Division of Cancer Epidemiology and Genetics, Department of Health and Human Services, National Cancer Institute, National Institutes of Health, Bethesda, MD; Department of Health and Human Services, Commissioned Corps of the United States Public Health Service, Washington, DC.
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Drandi D, Decruyenaere P, Ferrante M, Offner F, Vandesompele J, Ferrero S. Nucleic Acid Biomarkers in Waldenström Macroglobulinemia and IgM-MGUS: Current Insights and Clinical Relevance. Diagnostics (Basel) 2022; 12:diagnostics12040969. [PMID: 35454017 PMCID: PMC9028641 DOI: 10.3390/diagnostics12040969] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/07/2022] [Accepted: 04/09/2022] [Indexed: 12/13/2022] Open
Abstract
Waldenström Macroglobulinemia (WM) is an indolent lymphoplasmacytic lymphoma, characterized by the production of excess immunoglobulin M monoclonal protein. WM belongs to the spectrum of IgM gammopathies, ranging from asymptomatic IgM monoclonal gammopathy of undetermined significance (IgM-MGUS), through IgM-related disorders and asymptomatic WM to symptomatic WM. In recent years, its complex genomic and transcriptomic landscape has been extensively explored, hereby elucidating the biological mechanisms underlying disease onset, progression and therapy response. An increasing number of mutations, cytogenetic abnormalities, and molecular signatures have been described that have diagnostic, phenotype defining or prognostic implications. Moreover, cell-free nucleic acid biomarkers are increasingly being investigated, benefiting the patient in a minimally invasive way. This review aims to provide an extensive overview of molecular biomarkers in WM and IgM-MGUS, considering current shortcomings, as well as potential future applications in a precision medicine approach.
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Affiliation(s)
- Daniela Drandi
- Department of Molecular Biotechnology and Health Sciences, Hematology Division, University of Torino, 10126 Torino, Italy; (M.F.); (S.F.)
- Correspondence: (D.D.); (P.D.)
| | - Philippe Decruyenaere
- Department of Hematology, Ghent University Hospital, 9000 Ghent, Belgium;
- OncoRNALab, Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium;
- Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
- Correspondence: (D.D.); (P.D.)
| | - Martina Ferrante
- Department of Molecular Biotechnology and Health Sciences, Hematology Division, University of Torino, 10126 Torino, Italy; (M.F.); (S.F.)
| | - Fritz Offner
- Department of Hematology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Jo Vandesompele
- OncoRNALab, Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium;
- Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
| | - Simone Ferrero
- Department of Molecular Biotechnology and Health Sciences, Hematology Division, University of Torino, 10126 Torino, Italy; (M.F.); (S.F.)
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Durot E, Delmer A. Watch and wait in Waldenström macroglobulinaemia: looking for who to watch carefully and who can wait without worrying. Is it that simple? Br J Haematol 2021; 195:155-157. [PMID: 34472092 DOI: 10.1111/bjh.17699] [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: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 12/11/2022]
Affiliation(s)
- Eric Durot
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
| | - Alain Delmer
- Department of Hematology, University Hospital of Reims and UFR Médecine, Reims, France
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Defining an Ultra-Low Risk Group in Asymptomatic IgM Monoclonal Gammopathy. Cancers (Basel) 2021; 13:cancers13092055. [PMID: 33922804 PMCID: PMC8122982 DOI: 10.3390/cancers13092055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Patients with asymptomatic IgM monoclonal gammopathies include IgM monoclonal gammopathy of undetermined significance (IgM MGUS) and smoldering Waldenström macroglobulinemia (SWM), all with some risk of progression to symptomatic Waldenström macroglobulinemia, amyloidosis, or other lymphoproliferative disorder. Due to their low incidence, few studies have focused on the risk of progression, with SWM being the most studied. As both are recognized clinical-pathological entities that share similar clonal and phenotypical features, we focus on defining new biomarkers of progression in this population with long follow-up. Abstract We analyzed 171 patients with asymptomatic IgM monoclonal gammopathies (64 with IgM monoclonal gammopathy of undetermined significance—MGUS and 107 with smoldering Waldenström macroglobulinemia - SWM) who had a bone marrow (BM) evaluation performed at diagnosis. Abnormal free-light chain ratio (53% vs. 31%) and MYD88 mutation prevalence (66% vs. 30%) were higher in patients with SWM. No other differences were found among groups. With a median follow-up of 4.3 years, 14 patients progressed to Waldenström macroglobulinemia, 1 to amyloidosis, and 28 died without progression. The MYD88 mutation was found in 53% of patients (available in 160 patients). Multivariate analysis showed that immunoparesis (subhazard ratio—SHR 10.2, 95% confidence interval—CI: 4.2–24.8; p < 0.001) and BM lymphoplasmacytic infiltration ≥ 20% (SHR: 6, 95% CI: 1.6–22.1; p = 0.007) were associated with higher risk of progression. We developed a risk model based on these two risk factors. In the absence of both variables, an ultra-low risk group was identified (SHR 0.1, 95% CI 0.02–0.5; p = 0.004), with 3% and 6% of cumulative incidence of progression at 10 and 20 years, respectively. Bootstrap analysis confirmed the reproducibility of these results. This study finds immunoparesis and BM infiltration as biomarkers of progression as well as a low-risk group of progression in asymptomatic IgM monoclonal gammopathies.
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Gayet M, Leymarie V, Derouault P, Guérin E, Vaidié J, Pascal V, Boulin M, Dmytruk N, Chauzeix J, Trimoreau F, Gachard N, Feuillard J, Rizzo D. Flow cytometry detection of CD138 expression continuum between monotypic B and plasma cells is associated with both high IgM peak levels and MYD88 mutation and contributes to diagnosis of Waldenström macroglobulinemia. CYTOMETRY PART B-CLINICAL CYTOMETRY 2021; 102:62-69. [PMID: 33634586 DOI: 10.1002/cyto.b.21995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Differential diagnosis of Waldenström macroglobulinemia (WM) with other indolent B-cell malignancies is still a challenge. Here, we propose an original and simple analysis of routine flow cytometry (FCM) unraveling the characteristic ongoing plasma cell (PC) differentiation of WM tumor B-cells. METHODS FCM analysis of both B-cells and PC was performed on a series of 77 patients with IgM peak. MYD88 and CXCR4 mutations were studied using an allele-specific PCR and by high throughput sequencing. RESULTS Twenty seven (35%), 46 (58%) and 4 (5%) patients were classified as WM, IgM monoclonal gammopathy of undetermined significance (MGUS) or other B-NHL respectively. MYD88 mutation was found in 25/27 WM (93%) and in 29/46 MGUS (63%). Using FCM, monotypic B-cells were found in 27/27 WM (100%) and 34/46 MGUS (74%). Monotypic CD138pos/CD38pos PCs were detected in 23/27 WM (85%) and 25/46 MGUS (54%). Highlighting the ongoing PC differentiation of WM tumor B-cells by FCM, we evidenced a CD138 expression continuum between monotypic B-cells and PCs. This pattern remained absent in control samples and was significantly associated with higher IgM peaks (p = 6.10-5 ) and MYD88 mutations (p = 10-3 ) in both WM and MGUS cases. CONCLUSIONS FCM exploration of both B-cells and PC led to identify a CD138 expression continuum as an objective marker of ongoing PC differentiation of WM tumor cells and was strongly associated with increased IgM peak levels and MYD88 mutations. This approach could contribute to place FCM at the forefront of WM diagnosis.
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Affiliation(s)
- Mylene Gayet
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France
| | - Vincent Leymarie
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France
| | - Paco Derouault
- Department of Biochemistry and Molecular Biology, University Hospital Dupuytren, Limoges, France
| | - Estelle Guérin
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France.,UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France
| | - Julien Vaidié
- Clinical Hematology and Cellular Therapy, University Hospital Dupuytren, Limoges, France
| | - Virginie Pascal
- UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France.,Department of Immunology and Immunogenetics, University Hospital Dupuytren, Limoges, France
| | - Mélanie Boulin
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France
| | - Nataliya Dmytruk
- Clinical Hematology and Cellular Therapy, University Hospital Dupuytren, Limoges, France
| | - Jasmine Chauzeix
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France.,UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France
| | - Franck Trimoreau
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France
| | - Nathalie Gachard
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France.,UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France
| | - Jean Feuillard
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France.,UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France
| | - David Rizzo
- Biological Hematology Department, University Hospital Dupuytren, Limoges, France.,UMR CNRS 7276/INSERM 1262 - CRIBL, Faculty of Medicine, Limoges, France
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Bustoros M, Sklavenitis-Pistofidis R, Kapoor P, Liu CJ, Kastritis E, Zanwar S, Fell G, Abeykoon JP, Hornburg K, Neuse CJ, Marinac CR, Liu D, Soiffer J, Gavriatopoulou M, Boehner C, Cappuccio JM, Dumke H, Reyes K, Soiffer RJ, Kyle RA, Treon SP, Castillo JJ, Dimopoulos MA, Ansell SM, Trippa L, Ghobrial IM. Progression Risk Stratification of Asymptomatic Waldenström Macroglobulinemia. J Clin Oncol 2019; 37:1403-1411. [PMID: 30990729 DOI: 10.1200/jco.19.00394] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Waldenström macroglobulinemia (WM) is preceded by asymptomatic WM (AWM), for which the risk of progression to overt disease is not well defined. METHODS We studied 439 patients with AWM, who were diagnosed and observed at Dana-Farber Cancer Institute between 1992 and 2014. RESULTS During the 23-year study period, with a median follow-up of 7.8 years, 317 patients progressed to symptomatic WM (72%). Immunoglobulin M 4,500 mg/dL or greater, bone marrow lymphoplasmacytic infiltration 70% or greater, β2-microglobulin 4.0 mg/dL or greater, and albumin 3.5 g/dL or less were all identified as independent predictors of disease progression. To assess progression risk in patients with AWM, we trained and cross-validated a proportional hazards model using bone marrow infiltration, immunoglobulin M, albumin, and beta-2 microglobulin values as continuous measures. The model divided the cohort into three distinct risk groups: a high-risk group with a median time to progression (TTP) of 1.8 years, an intermediate-risk group with a median TTP of 4.8 years, and a low-risk group with a median TTP of 9.3 years. We validated this model in two external cohorts, demonstrating robustness and generalizability. For clinical applicability, we made the model available as a Web page application ( www.awmrisk.com ). By combining two cohorts, we were powered to identify wild type MYD88 as an independent predictor of progression (hazard ratio, 2.7). CONCLUSION This classification system is positioned to inform patient monitoring and care and, for the first time to our knowledge, to identify patients with high-risk AWM who may need closer follow-up or benefit from early intervention.
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Affiliation(s)
- Mark Bustoros
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
| | | | | | - Chia-Jen Liu
- 1 Dana-Farber Cancer Institute, Boston, MA.,5 Tapei Veterans General Hospital, Taipei, Taiwan.,6 National Yang-Ming University, Taipei, Taiwan
| | | | | | | | | | | | - Carl Jannes Neuse
- 1 Dana-Farber Cancer Institute, Boston, MA.,8 University of Münster Faculty of Medicine, Münster, Germany
| | - Catherine R Marinac
- 1 Dana-Farber Cancer Institute, Boston, MA.,2 Harvard T.H. Chan School of Public Health, Boston, MA
| | - David Liu
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
| | - Jenny Soiffer
- 1 Dana-Farber Cancer Institute, Boston, MA.,9 University of Miami Miller School of Medicine, Miami, FL
| | | | - Cody Boehner
- 1 Dana-Farber Cancer Institute, Boston, MA.,10 University of Massachusetts, Boston, MA
| | | | | | | | - Robert J Soiffer
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
| | | | - Steven P Treon
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
| | - Jorge J Castillo
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
| | | | | | - Lorenzo Trippa
- 1 Dana-Farber Cancer Institute, Boston, MA.,2 Harvard T.H. Chan School of Public Health, Boston, MA
| | - Irene M Ghobrial
- 1 Dana-Farber Cancer Institute, Boston, MA.,3 Harvard Medical School, Boston, MA
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High-Dose Therapy and Hematopoietic Stem Cell Transplantation in Waldenström Macroglobulinemia. Hematol Oncol Clin North Am 2018; 32:865-874. [PMID: 30190024 DOI: 10.1016/j.hoc.2018.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Waldenström macroglobulinemia (WM) is an indolent low-grade non-Hodgkin lymphoma characterized by bone marrow infiltration by lymphoplasmacytic cells and associated clonal IgM paraproteinemia. Recent insights into the biology and genomic characteristics of WM have provided a further platform for more targeted therapies. Despite the high response rates and better depth and duration of responses, the disease remains incurable. This review focuses on use of the high-dose therapy with either autologous or allogeneic hematopoietic stem cell transplantation.
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Pophali PA, Bartley A, Kapoor P, Gonsalves WI, Ashrani AA, Marshall AL, Siddiqui MA, Kyle RA, Go RS. Prevalence and survival of smouldering Waldenström macroglobulinaemia in the United States. Br J Haematol 2018. [PMID: 29532912 DOI: 10.1111/bjh.15201] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Priyanka A Pophali
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Adam Bartley
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wilson I Gonsalves
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aneel A Ashrani
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ariela L Marshall
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Robert A Kyle
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ronald S Go
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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13
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Tanaka H, Sakuma Y, Ikeda H, Shimizu R, Sugita Y, Iwai R. Characteristics and Prognosis of Patients with Immunoglobulin M Monoclonal Gammopathy. J Clin Exp Hematop 2018; 57:47-53. [PMID: 29021514 DOI: 10.3960/jslrt.17025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Many patients with immunoglobulin M (IgM) monoclonal gammopathy remain asymptomatic and, consequently, untreated; however, few studies have evaluated the clinical course and prognosis of these patients. Using the screening procedures at our hospital, 74 patients with IgM monoclonal gammopathy were selected. We excluded 11 patients in whom the treatment for lymphoid neoplasms had been initiated at the time of IgM monoclonal protein detection. The remaining 63 patients were considered to be the patient population with IgM MGUS and asymptomatic WM, and were analyzed. In these patients, the median overall survival was longer than 14 years. More than half of these patients died from causes other than lymphoid neoplasm. The cumulative incidence of lymphoid neoplasm requiring treatment was 17.5%. In five of eight patients requiring treatment for lymphoid neoplasms, the causes of death were related with these lymphoid neoplasms. Our study suggests that not all patients with IgM monoclonal gammopathy require uniform treatment for prolonged survival; however, most lymphoid neoplasms requiring treatment are refractory diseases. Our findings may help manage patients with macroglobulinemia.
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Affiliation(s)
| | - Yukie Sakuma
- Clinical Research Support Center, Asahi General Hospital
| | - Hideki Ikeda
- Department of Internal Medicine, Asahi General Hospital
| | - Ryo Shimizu
- Department of Hematology, Asahi General Hospital
| | | | - Rie Iwai
- Department of Transfusion Medicine, Asahi General Hospital
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14
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Huang H, Luo Y, Liang Y, Long XD, Peng Y, Liu Z, Wen X, Jia M, Tian R, Bai C, Li C, Dong X. CD4+CD25+ cells in multiple myeloma related renal impairment. Sci Rep 2015; 5:16565. [PMID: 26564056 PMCID: PMC4643310 DOI: 10.1038/srep16565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022] Open
Abstract
CD4+CD25+ cells are critical regulators in almost all of the animal models of human organ-specific autoimmune diseases, transplant rejection and allergic diseases. We aimed to explore the role of CD4+CD25+ cells in the pathogenesis of multiple myeloma (MM) related renal impairment (RI). Thirty patients with MM related RI and 30 healthy volunteers were studied. The number of CD4+CD25+ cells was examined by flow cytometry. Clinical and laboratory data were collected from each subject. Glomerular injury was assessed by histopathology. Serum IL-2, IL-4 and IL-6 were analyzed by ELISA. CD4+CD25+ cells significantly decreased in MM related RI patients compared to the controls (P<0.05). CD4+CD25+ cell number was negatively associated with blood urea nitrogen (BUN), supernatant IL-4, serum IL-6, monoclonal immunoglobulin and β2-microglobulin, as well as bone marrow plasma cell percentage and proteinuria; whereas positively associated with estimated glomerular filtration rate (eGFR) (all P < 0.05). CD4+CD25+ cells gradually decreased as the Clinic Stage increased. The number of CD4+CD25+ cells reduced in MM related RI patients, and was correlated with disease severity. CD4+CD25+ cells may play an important role in the pathogenesis of MM related RI.
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Affiliation(s)
- Hongdong Huang
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China.,Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, P.R. China
| | - Yang Luo
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Yumei Liang
- Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, P.R. China
| | - Xi-Dai Long
- Department of Liver Surgery, the Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Youming Peng
- Hunan Key Laboratory of Nephrology and Hemoperfusion, Division of Nephrology, Second Xiangya Hospital of Central South University, Changsha, Hunan Province, P.R. China
| | - Zhihua Liu
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Xiaojun Wen
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Meng Jia
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Ru Tian
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Chengli Bai
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Cui Li
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Xiaoqun Dong
- Section of Hematology/Oncology, Section of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, USA
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15
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The cellular origin and malignant transformation of Waldenström macroglobulinemia. Blood 2015; 125:2370-80. [DOI: 10.1182/blood-2014-09-602565] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/27/2015] [Indexed: 01/14/2023] Open
Abstract
Key Points
Benign (ie, IgM MGUS and smoldering WM) clonal B cells already harbor the phenotypic and molecular signatures of the malignant WM clone. Multistep transformation from benign (ie, IgM MGUS and smoldering WM) to malignant WM may require specific copy number abnormalities.
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16
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Oza A, Rajkumar SV. Waldenstrom macroglobulinemia: prognosis and management. Blood Cancer J 2015; 5:e394. [PMID: 25815903 PMCID: PMC4382666 DOI: 10.1038/bcj.2015.28] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 12/12/2022] Open
Abstract
Waldenstrom macroglobulinemia (WM) is a B-cell lymphoplasmacytic lymphoma characterized by monoclonal immunoglobulin M protein in the serum and infiltration of bone marrow with lymphoplasmacytic cells. Asymptomatic patients can be observed without therapy. First-line therapy should consist of the monoclonal anti-CD20 antibody, rituximab, given typically in combination with other agents. We prefer dexamethasone, rituximab, cyclophosphamide (DRC) as initial therapy for most patients with symptomatic WM. Other reasonable options are bortezomib, rituximab, dexamethasone (BoRD) or bendamustine plus rituximab (BR). All of these regimens are associated with excellent response and tolerability. Initial therapy is usually administered for 6 months, followed by observation. Response to therapy is assessed using the standard response criteria developed by the International Working Group on Waldenstrom macroglobulinemia. Relapse is almost inevitable in WM but may occur years after initial therapy. In symptomatic patients relapsing more than 1–2 years after initial therapy, the original treatment can be repeated. For relapse occurring sooner, an alternative regimen is used. In select patients, high-dose chemotherapy followed by autologous hematopoietic cell transplantation may be an option at relapse. Options for therapy of relapsed WM besides regimens used in the front-line setting include ibrutinib, purine nucleoside analogs (cladribine, fludarabine), carfilzomib and immunomodulatory agents (thalidomide, lenalidomide).
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Affiliation(s)
- A Oza
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - S V Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
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17
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Rajkumar SV. Multiple myeloma: 2014 Update on diagnosis, risk-stratification, and management. Am J Hematol 2014; 89:999-1009. [PMID: 25223428 DOI: 10.1002/ajh.23810] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 12/21/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires 10% or more clonal plasma cells on bone marrow examination or a biopsy proven plasmacytoma plus evidence of associated end-organ damage. If end-organ damage is not present, the presence of 60% or more clonal plasma cells in the marrow is also considered as myeloma. RISK STRATIFICATION In the absence of concurrent trisomies, patients with 17p deletion, t(14;16), and t(14;20) are considered to have high-risk myeloma. Patients with t(4;14) translocation are considered intermediate-risk. All others are considered as standard-risk. Risk-adapted initial therapy: Standard-risk patients can be treated with lenalidomide plus low-dose dexamethasone (Rd), or a bortezomib-containing triplet such as bortezomib, cyclophosphamide, dexamethasone (VCD). Intermediate-risk and high-risk patients require a bortezomib-based triplet regimen. In eligible patients, initial therapy is given for approximately 4 months followed by autologous stem cell transplantation (ASCT). Standard risk patients can opt for delayed ASCT if stem cells can be cryopreserved. In patients who are not candidates for transplant, initial therapy is given for approximately 12 to 18 months. Maintenance therapy: After initial therapy, lenalidomide maintenance is considered for standard risk patients who are not in very good partial response or better, while maintenance with a bortezomib-based regimen should be considered in patients with intermediate or high risk myeloma. Management of refractory disease: Patients with indolent relapse can be treated first with 2-drug or 3-drug combinations. Patients with more aggressive relapse often require therapy with a combination of multiple active agents.
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18
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van de Donk NWCJ, Palumbo A, Johnsen HE, Engelhardt M, Gay F, Gregersen H, Hajek R, Kleber M, Ludwig H, Morgan G, Musto P, Plesner T, Sezer O, Terpos E, Waage A, Zweegman S, Einsele H, Sonneveld P, Lokhorst HM. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99:984-96. [PMID: 24658815 PMCID: PMC4040895 DOI: 10.3324/haematol.2013.100552] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 03/14/2014] [Indexed: 12/18/2022] Open
Abstract
Monoclonal gammopathy of undetermined significance is one of the most common pre-malignant disorders. IgG and IgA monoclonal gammopathy of undetermined significance are precursor conditions of multiple myeloma; light-chain monoclonal gammopathy of undetermined significance of light-chain multiple myeloma; and IgM monoclonal gammopathy of undetermined significance of Waldenström's macroglobulinemia and other lymphoproliferative disorders. Clonal burden, as determined by bone marrow plasma cell percentage or M-protein level, as well as biological characteristics, including heavy chain isotype and light chain production, are helpful in predicting risk of progression of monoclonal gammopathy of undetermined significance to symptomatic disease. Furthermore, alterations in the bone marrow microenvironment of monoclonal gammopathy of undetermined significance patients result in an increased risk of venous and arterial thrombosis, infections, osteoporosis, and bone fractures. In addition, the small clone may occasionally be responsible for severe organ damage through the production of a monoclonal protein that has autoantibody activity or deposits in tissues. These disorders are rare and often require therapy directed at eradication of the underlying plasma cell or lymphoplasmacytic clone. In this review, we provide an overview of the clinical relevance of monoclonal gammopathy of undetermined significance. We also give general recommendations of how to diagnose and manage patients with monoclonal gammopathy of undetermined significance.
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Affiliation(s)
| | - Antonio Palumbo
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Hans Erik Johnsen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Monika Engelhardt
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Francesca Gay
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Turin, Italy
| | - Henrik Gregersen
- Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Roman Hajek
- Department of Haemato-oncology, University Hospital Ostrava and Faculty of Medicine, Czech Republic
| | - Martina Kleber
- Department of Hematology and Oncology, University of Freiburg Medical Center, Germany
| | - Heinz Ludwig
- Department of Medicine I, Wilhelminenspital Wien, Austria
| | - Gareth Morgan
- Institute of Cancer Research, Royal Marsden Hospital, London, UK
| | - Pellegrino Musto
- Scientific Direction, Centro di Riferimento Oncologico della Basilicata, Istituto di Ricovero e Cura a Carattere Scientifico, Rionero in Vulture, Italy
| | | | - Orhan Sezer
- Department of Hematology, Memorial Hospital, Istanbul, Turkey
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens School of Medicine, Greece
| | - Anders Waage
- Department of Hematology, St. Olavs Hospital, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Hermann Einsele
- Universitätsklinik Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henk M Lokhorst
- Department of Hematology, University Medical Center Utrecht, The Netherlands
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19
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The genomic landscape of Waldenström macroglobulinemia is characterized by highly recurring MYD88 and WHIM-like CXCR4 mutations, and small somatic deletions associated with B-cell lymphomagenesis. Blood 2014; 123:1637-46. [DOI: 10.1182/blood-2013-09-525808] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Key Points
Highly recurring mutations are present in WM, including MYD88 L265P, warts, hypogammaglobulinemia, infection, and myelokathexis-syndrome–like mutations in CXCR4, and ARID1A. Small, previously undetected CNAs affecting B-cell regulatory genes are highly prevalent in WM.
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20
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García-Sanz R, Ocio EM. Novel treatment regimens for Waldenström’s macroglobulinemia. Expert Rev Hematol 2014; 3:339-50. [DOI: 10.1586/ehm.10.19] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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21
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Multiparameter flow cytometry for the identification of the Waldenström’s clone in IgM-MGUS and Waldenström’s Macroglobulinemia: new criteria for differential diagnosis and risk stratification. Leukemia 2013; 28:166-73. [DOI: 10.1038/leu.2013.124] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 04/10/2013] [Accepted: 04/12/2013] [Indexed: 12/27/2022]
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22
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Prevalence and clinical significance of the MYD88 (L265P) somatic mutation in Waldenström’s macroglobulinemia and related lymphoid neoplasms. Blood 2013; 121:2522-8. [DOI: 10.1182/blood-2012-09-457101] [Citation(s) in RCA: 242] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Key Points
Using a sensitive method, the MYD88 (L265P) mutation is detectable in all patients with Waldenström’s macroglobulinemia, therefore representing a hallmark of the disease. MYD88 (L265P) is also found in a substantial proportion of patients with IgM-MGUS.
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23
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Kyle RA, Therneau TM, Dispenzieri A, Kumar S, Benson JT, Larson DR, Melton LJ, Rajkumar SV. Immunoglobulin m monoclonal gammopathy of undetermined significance and smoldering Waldenström macroglobulinemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13:184-6. [PMID: 23490989 DOI: 10.1016/j.clml.2013.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Monoclonal gammopathy of undetermined significance of the immunoglobulin M class was diagnosed in 213 patients at the Mayo Clinic, 29 (14%) of whom developed lymphoma, Waldenström macroglobulinemia, or a related disorder over 1567 person-years of follow-up. The cumulative probability of progression was 10% at 5 years, 18% at 10 years, and 24% at 15 years, or approximately 1.5% per year. The concentration of serum monoclonal protein at diagnosis and the initial serum albumin value were the only independent predictors of progression with multivariate analysis. By contrast, during 285 person-years of follow-up, 34 (71%) of 48 patients with smoldering Waldenström macroglobulinemia (SWM) progressed to Waldenström macroglobulinemia (WM), which required therapy, along with amyloid light chain (AL) amyloidosis (1) and lymphoma (1). The cumulative probability of progression was 6% at 1 year, 39% at 3 years, 59% at 5 years, and 65% at 10 years. The percentage of lymphoplasmacytic cells in the bone marrow, size of the serum monoclonal (M) spike, and hemoglobin value were significant independent risk factors for progression.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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24
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Rajkumar SV. Multiple myeloma: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol 2013; 88:226-35. [PMID: 23440663 DOI: 10.1002/ajh.23390] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 01/08/2013] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma accounts for approximately 10% of hematologic malignancies. DIAGNOSIS The diagnosis requires 10% or more clonal plasma cells on bone marrow examination or a biopsy proven plasmacytoma plus evidence of associated end-organ damage. In addition, the presence of 60% or more clonal plasma cells in the marrow is also considered as myeloma regardless of the presence or absence of end-organ damage. RISK STRATIFICATION In the absence of concurrent trisomies, patients with 17p deletion, t(14;16), and t(14;20) are considered to have high-risk myeloma. Patients with t(4;14) translocation are considered intermediate-risk. All others are considered as standard-risk. RISK-ADAPTED INITIAL THERAPY: Standard-risk patients can be treated with lenalidomide plus low-dose dexamethasone (Rd), or a bortezomib-containing triplet such as bortezomib, cyclophosphamide, dexamethasone (VCD). Intermediate-risk and high-risk patients require a bortezomib-based triplet regimen. In eligible patients, initial therapy is given for approximately 4 months followed by autologous stem cell transplantation (ASCT). Standard-risk patients can opt for delayed ASCT if stem cells can be cryopreserved. In patients are not candidates for transplant, initial therapy is given for approximately 12-18 months. MAINTENANCE THERAPY After initial therapy, lenalidomide maintenance is considered for standard-risk patients who are not in very good partial response or better, while maintenance with a bortezomib-based regimen should be considered in pateints with intermediate or high-risk myeloma. MANAGEMENT OF REFRACTORY DISEASE Patients with indolent relapse can be treated first with two-drug or three-drug combinations. Patients with more aggressive relapse often require therapy with a combination of multiple active agents.
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Affiliation(s)
- S. Vincent Rajkumar
- Division of Hematology; Mayo Clinic College of Medicine; Rochester; Minnesota
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25
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MYD88 L265P in Waldenström macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction. Blood 2013; 121:2051-8. [PMID: 23321251 DOI: 10.1182/blood-2012-09-454355] [Citation(s) in RCA: 316] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
By whole-genome and/or Sanger sequencing, we recently identified a somatic mutation (MYD88 L265P) that stimulates nuclear factor κB activity and is present in >90% of Waldenström macroglobulinemia (WM) patients. MYD88 L265P was absent in 90% of immunoglobulin M (IgM) monoclonal gammopathy of undetermined significance (MGUS) patients. We therefore developed conventional and real-time allele-specific polymerase chain reaction (AS-PCR) assays for more sensitive detection and quantification of MYD88 L265P. Using either assay, MYD88 L265P was detected in 97 of 104 (93%) WM and 13 of 24 (54%) IgM MGUS patients and was either absent or rarely expressed in samples from splenic marginal zone lymphoma (2/20; 10%), CLL (1/26; 4%), multiple myeloma (including IgM cases, 0/14), and immunoglobulin G MGUS (0/9) patients as well as healthy donors (0/40; P < 1.5 × 10(-5) for WM vs other cohorts). Real-time AS-PCR identified IgM MGUS patients progressing to WM and showed a high rate of concordance between MYD88 L265P ΔCT and BM disease involvement (r = 0.89, P = .008) in WM patients undergoing treatment. These studies identify MYD88 L265P as a widely present mutation in WM and IgM MGUS patients using highly sensitive and specific AS-PCR assays with potential use in diagnostic discrimination and/or response assessment. The finding of this mutation in many IgM MGUS patients suggests that MYD88 L265P may be an early oncogenic event in WM pathogenesis.
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26
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Treon SP, Xu L, Yang G, Zhou Y, Liu X, Cao Y, Sheehy P, Manning RJ, Patterson CJ, Tripsas C, Arcaini L, Pinkus GS, Rodig SJ, Sohani AR, Harris NL, Laramie JM, Skifter DA, Lincoln SE, Hunter ZR. MYD88 L265P somatic mutation in Waldenström's macroglobulinemia. N Engl J Med 2012; 367:826-33. [PMID: 22931316 DOI: 10.1056/nejmoa1200710] [Citation(s) in RCA: 872] [Impact Index Per Article: 72.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Waldenström's macroglobulinemia is an incurable, IgM-secreting lymphoplasmacytic lymphoma (LPL). The underlying mutation in this disorder has not been delineated. METHODS We performed whole-genome sequencing of bone marrow LPL cells in 30 patients with Waldenström's macroglobulinemia, with paired normal-tissue and tumor-tissue sequencing in 10 patients. Sanger sequencing was used to validate the findings in samples from an expanded cohort of patients with LPL, those with other B-cell disorders that have some of the same features as LPL, and healthy donors. RESULTS Among the patients with Waldenström's macroglobulinemia, a somatic variant (T→C) in LPL cells was identified at position 38182641 at 3p22.2 in the samples from all 10 patients with paired tissue samples and in 17 of 20 samples from patients with unpaired samples. This variant predicted an amino acid change (L265P) in MYD88, a mutation that triggers IRAK-mediated NF-κB signaling. Sanger sequencing identified MYD88 L265P in tumor samples from 49 of 54 patients with Waldenström's macroglobulinemia and in 3 of 3 patients with non-IgM-secreting LPL (91% of all patients with LPL). MYD88 L265P was absent in paired normal tissue samples from patients with Waldenström's macroglobulinemia or non-IgM LPL and in B cells from healthy donors and was absent or rarely expressed in samples from patients with multiple myeloma, marginal-zone lymphoma, or IgM monoclonal gammopathy of unknown significance. Inhibition of MYD88 signaling reduced IκBα and NF-κB p65 phosphorylation, as well as NF-κB nuclear staining, in Waldenström's macroglobulinemia cells expressing MYD88 L265P. Somatic variants in ARID1A in 5 of 30 patients (17%), leading to a premature stop or frameshift, were also identified and were associated with an increased disease burden. In addition, 2 of 3 patients with Waldenström's macroglobulinemia who had wild-type MYD88 had somatic variants in MLL2. CONCLUSIONS MYD88 L265P is a commonly recurring mutation in patients with Waldenström's macroglobulinemia that can be useful in differentiating Waldenström's macroglobulinemia and non-IgM LPL from B-cell disorders that have some of the same features. (Funded by the Peter and Helen Bing Foundation and others.).
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Affiliation(s)
- Steven P Treon
- Bing Center for Waldenström's Macroglobulinemia, Dana–Farber Cancer Institute, M547, 450 Brookline Ave., Boston, MA 02115, USA.
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27
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Abstract
Waldenström macroglobulinemia is characterized by the production of serum monoclonal IgM and lymphoplasmacytic bone marrow infiltration. At least 25% of patients are asymptomatic at diagnosis and treatment is only mandatory in cases of symptomatic disease. Beside reports on treatment results, reviewing risk assessment is another way to describe the clinical course of the disease. This information may be particularly useful when numerous treatment options are available. While the introduction of new treatment approaches reinforces the need for careful risk assessment, the identification of useful prognostic information requires prolonged follow-up in patients who have not been treated with current therapeutic options. This limitation should be taken into account when using and interpreting available prognostic information, especially survival estimates.
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Affiliation(s)
- Pierre Morel
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Italy.
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28
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Abstract
The purpose of this study was to define the risk of progression and survival of patients with smoldering Waldenström macroglobulinemia (SWM). SWM is defined clinically as having a serum monoclonal IgM protein≥3 g/dL and/or≥10% bone marrow lymphoplasmacytic infiltration but no evidence of end-organ damage (anemia, constitutional symptoms, hyperviscosity, lymphadenopathy, or hepatosplenomegaly). We searched a computerized database and reviewed the medical records of all patients at Mayo Clinic who fulfilled the criteria of SWM between 1974 and 1995. During 285 cumulative person-years of follow-up of the 48 patients with SWM (median, 15.4 years), 34 (71%) progressed to symptomatic Waldenström macroglobulinemia (WM) requiring treatment, one to primary amyloidosis, and one to lymphoma (total, 75%). The cumulative probability of progression to symptomatic WM, amyloidosis, or lymphoma was 6% at 1 year, 39% at 3 years, 59% at 5 years, and 68% at 10 years. The major risk factors for progression were percentage of lymphoplasmacytic cells in the bone marrow, size of the serum M-spike, and the hemoglobin value. Patients with SWM should be followed and not treated until symptomatic WM develops. Treatment on a clinical trial for those at greatest risk of progression should be considered.
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29
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Abstract
DISEASE OVERVIEW Multiple myeloma accounts for ∼10% of all hematologic malignancies. DIAGNOSIS The diagnosis requires 10% or more clonal plasma cells on bone marrow examination or a biopsy proven plasmacytoma plus evidence of end-organ damage felt to be related to the underlying plasma-cell disorder. RISK STRATIFICATION Patients with 17p deletion, t(14;16), t(14;20), or high-risk gene expression profiling signature have high-risk myeloma. Patients with t(4;14) translocation, karyotypic deletion 13, or hypodiploidy are considered to have intermediate-risk disease. All others are considered to have standard-risk myeloma. RISK-ADAPTED THERAPY Standard-risk patients are treated with nonalkylator-based therapy such as lenalidomide plus low-dose dexamethasone (Rd) followed by autologous stem-cell transplantation (ASCT). An alternative strategy is to continue initial therapy after stem-cell collection, reserving ASCT for first relapse. Intermediate-risk and high-risk patients are treated with a bortezomib-based induction followed by ASCT and then bortezomib-based maintenance. Patients not eligible for ASCT can be treated with Rd for standard risk disease, or with a bortezomib-based regimen if intermediate-risk or high-risk features are present. To reduce toxicity, when using bortezomib, the once-weekly subcutaneous dose is preferred; similarly, when using dexamethasone, the low-dose approach (40 mg once a week) is preferred, unless there is a need for rapid disease control. MANAGEMENT OF REFRACTORY DISEASE Patients with indolent relapse can be treated first with two-drug or three-drug combinations. Patients with more aggressive relapse often require therapy with a combination of multiple active agents. The most promising new agents in development are pomalidomide and carfilizomib.
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30
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Greco A, Tedeschi A, Varettoni M, Nichelatti M, Paris L, Ricci F, Vismara E, Morra E. Factors predicting transformation of asymptomatic IgM monoclonal gammopathy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:77-9. [PMID: 21454196 DOI: 10.3816/clml.2011.n.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We evaluated the risk of transformation of asymptomatic immunoglobulin (Ig) M monoclonal gammopathy (aIgM MG) into symptomatic lymphoproliferative disease in 287 patients all analyzed for bone marrow histopathology and immunophenotyping. This series included 201 patients with IgM MG of undetermined significance (IgM MGUS) and 86 with smoldering Waldenström's macroglobulinemia (sWM). After a median of 50 months (range, 12-322 months), 32 cases of aIgM-MG (11.1%) evolved into symptomatic malignant lymphoproliferative disease, as follows: symptomatic WM (n=26), non-Hodgkin lymphoma (n=6). The cumulative transformation percentage at 5 and 10 years was 8% and 19.5%, respectively. The parameters significantly correlated with evolution were, at univariate analysis, BM lymphoplasmacytic infiltration, high erythrocyte sedimentation rate, serum MC, serum IgM size, and serum IgA size. Among patients with aIgM-MG, those at high risk of evolution were patients with sWM, a distinct entity with serum IgM monoclonal protein≥3 g/dL and/or ≥10% bone marrow lymphoplasmacytic infiltration.
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Affiliation(s)
- Antonino Greco
- Division of Hematology, Niguarda Ca' Granda Hospital, Milan, Italy
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31
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Landgren O, Kyle RA, Rajkumar SV. From myeloma precursor disease to multiple myeloma: new diagnostic concepts and opportunities for early intervention. Clin Cancer Res 2011; 17:1243-52. [PMID: 21411440 PMCID: PMC5901666 DOI: 10.1158/1078-0432.ccr-10-1822] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Since monoclonal gammopathy of undetermined significance (MGUS) was first described more than 30 years ago, the definition of the entity has evolved. Today, 3 distinct clinical MGUS subtypes have been defined: non-immunoglobulin M (IgM; IgG or IgA) MGUS, IgM MGUS, and light chain MGUS. Each clinical MGUS subtype is characterized by unique intermediate stages and progression events. Although we now have strong evidence that multiple myeloma is consistently preceded by a precursor state at the molecular level, there is urgent need to better understand mechanisms that regulate transformation from precursor to full-blown multiple myeloma. In the future, if such knowledge was available, it would allow clinicians to define high-risk and low-risk precursor patients for a more tailored clinical management. Also, it would provide insights on the individual patient's disease biology, which, in turn, can be used for targeted and more individualized treatment strategies. On the basis of current clinical guidelines, patients diagnosed with MGUS and smoldering myeloma should not be treated outside of clinical trials. In the near future, it seems reasonable to believe that high-risk precursor patients will likely become candidates for early treatment strategies. In this review, we discuss novel insights from recent studies and propose future directions of relevance for clinical management and research studies.
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Affiliation(s)
- Ola Landgren
- Center for Cancer Research, National Cancer Institute, NIH, Bethesda, Maryland 20892, USA.
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Ocio EM, Carpio DD, Caballero Á, Alonso J, Paiva B, Pesoa R, Villaescusa T, López-Anglada L, Vidriales B, García-Sanz R. Differential Diagnosis of IgM MGUS and WM According to B-Lymphoid Infiltration by Morphology and Flow Cytometry. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:93-5. [DOI: 10.3816/clml.2011.n.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Terpos E, Tasidou A, Eleftherakis-Papaiakovou E, Christoulas D, Gavriatopoulou M, Gkotzamanidou M, Roussou M, Kastritis E, Papadaki T, Dimopoulos MA. Expression of CCL3 by Neoplastic Cells in Patients with Waldenström's Macroglobulinemia: An Immunohistochemical Study in Bone Marrow Biopsies of 67 Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:115-7. [DOI: 10.3816/clml.2011.n.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Rajkumar SV. Multiple myeloma: 2011 update on diagnosis, risk-stratification, and management. Am J Hematol 2011; 86:57-65. [PMID: 21181954 DOI: 10.1002/ajh.21913] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
DISEASE OVERVIEW Multiple myeloma is malignant plasma-cell disorder that accounts for ∼10% of all hematologic malignancies. DIAGNOSIS The diagnosis requires (1) 10% or more clonal plasma cells on bone marrow examination or a biopsy-proven plasmacytoma plus (2) evidence of end-organ damage felt to be related to the underlying plasma cell disorder. RISK STRATIFICATION Patients with 17p deletion, t(4;14), t(14;16), t(14;20), and karyotypic deletion 13 or hypodiploidy are considered to have high-risk myeloma. All others are considered to have standard-risk disease. RISK-ADAPTED THERAPY Standard-risk patients are treated with nonalkylator-based therapy such as lenalidomide plus low-dose dexamethasone (Rd) followed by autologous stem-cell transplantation (ASCT). If patients are tolerating the induction regimen treatment well, an alternative strategy is to continue initial therapy after stem-cell collection, reserving ASCT for first relapse. High-risk patients are treated with a bortezomib-based induction followed by ASCT and then bortezomib-based maintenance. Patients not eligible for ASCT can be treated with Rd for standard risk disease or a bortezomib-based regimen if high-risk features are present. To reduce toxicity, when using bortezomib, the once-weekly dose is preferred; similarly, when using dexamethasone, the low-dose approach (40 mg once a week) is preferred, unless there is a need for rapid disease control. MANAGEMENT OF REFRACTORY DISEASE Patients with indolent relapse can be treated first with lenalidomide, bortezomib, or alkylators plus low-dose corticosteroids. Patients with more aggressive relapse often require therapy with a combination of multiple active agents. The most promising new agents in development are pomalidomide and carfilizomib.
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Affiliation(s)
- S Vincent Rajkumar
- Division of Hematology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
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McMaster ML, Landgren O. Prevalence, clinical aspects, and natural history of IgM MGUS. CYTOMETRY PART B-CLINICAL CYTOMETRY 2010; 78 Suppl 1:S91-7. [PMID: 20839342 DOI: 10.1002/cyto.b.20550] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Waldenström macroglobulinemia (WM) and chronic lymphocytic leukemia (CLL) are related B-cell cancers that share several clinical and biological features. Both WM and CLL have associated precursor conditions: monoclonal gammopathy of undetermined significance (MGUS) of immunoglobulin M (IgM) type and monoclonal B-cell lymphocytosis (MBL), respectively. Recently, a case of MBL with an IgM MGUS was reported, suggesting a close biological relationship between these entities. While much is known about MGUS overall, investigations of IgM MGUS specifically have been fragmentary. METHODS In this article, we review data on the prevalence, clinical aspects and natural history of IgM MGUS, and focus on identifying gaps in our understanding of the complex relationships among B-cell malignancies and their precursors. RESULTS There appears to be marked heterogeneity in the prevalence of IgM MGUS across populations. However, studies have varied in definition, design, laboratory methods, and endpoints. IgM MGUS differs from non-IgM MGUS in certain respects, including prevalence across racial groups, rate of progression, and pattern of malignant outcomes. There are limited data regarding the coincident occurrence of IgM MGUS and MBL. CONCLUSIONS Future studies incorporating both protein electrophoresis and flow cytometry are needed to define the underlying spectrum and causes of precursor development, risk factors for progression, and markers that distinguish low- and high-risk precursor patients.
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Affiliation(s)
- Mary L McMaster
- Genetic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892-7236, USA.
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Rajkumar SV, Kyle RA, Buadi FK. Advances in the diagnosis, classification, risk stratification, and management of monoclonal gammopathy of undetermined significance: implications for recategorizing disease entities in the presence of evolving scientific evidence. Mayo Clin Proc 2010; 85:945-8. [PMID: 20884827 PMCID: PMC2947967 DOI: 10.4065/mcp.2010.0520] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Ansell SM, Kyle RA, Reeder CB, Fonseca R, Mikhael JR, Morice WG, Bergsagel PL, Buadi FK, Colgan JP, Dingli D, Dispenzieri A, Greipp PR, Habermann TM, Hayman SR, Inwards DJ, Johnston PB, Kumar SK, Lacy MQ, Lust JA, Markovic SN, Micallef INM, Nowakowski GS, Porrata LF, Roy V, Russell SJ, Short KED, Stewart AK, Thompson CA, Witzig TE, Zeldenrust SR, Dalton RJ, Rajkumar SV, Gertz MA. Diagnosis and management of Waldenström macroglobulinemia: Mayo stratification of macroglobulinemia and risk-adapted therapy (mSMART) guidelines. Mayo Clin Proc 2010; 85:824-33. [PMID: 20702770 PMCID: PMC2931618 DOI: 10.4065/mcp.2010.0304] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Waldenström macroglobulinemia is a B-cell malignancy with lymphoplasmacytic infiltration in the bone marrow or lymphatic tissue and a monoclonal immunoglobulin M protein (IgM) in the serum. It is incurable with current therapy, and the decision to treat patients as well as the choice of treatment can be complex. Using a risk-adapted approach, we provide recommendations on timing and choice of therapy. Patients with smoldering or asymptomatic Waldenström macroglobulinemia and preserved hematologic function should be observed without therapy. Symptomatic patients with modest hematologic compromise, IgM-related neuropathy that requires therapy, or hemolytic anemia unresponsive to corticosteroids should receive standard doses of rituximab alone without maintenance therapy. Patients who have severe constitutional symptoms, profound hematologic compromise, symptomatic bulky disease, or hyperviscosity should be treated with the DRC (dexamethasone, rituximab, cyclophosphamide) regimen. Any patient with symptoms of hyperviscosity should first be treated with plasmapheresis. For patients who experience relapse after a response to initial therapy of more than 2 years' duration, the original therapy should be repeated. For patients who had an inadequate response to initial therapy or a response of less than 2 years' duration, an alternative agent or combination should be used. Autologous stem cell transplant should be considered in all eligible patients with relapsed disease.
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Affiliation(s)
- Stephen M Ansell
- Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Hellqvist E, Kvarnström M, Söderberg A, Vrethem M, Ernerudh J, Rosén A. Myelin protein zero is naturally processed in the B cells of monoclonal gammopathy of undetermined significance of immunoglobulin M isotype: aberrant triggering of a patient's T cells. Haematologica 2009; 95:627-36. [PMID: 20015874 DOI: 10.3324/haematol.2009.015123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Monoclonal gammopathy of undetermined significance of immunoglobulin M isotype is a condition with clonally expanded B cells, recently suggested to have an infectious origin. This monoclonal gammopathy is frequently associated with polyneuropathy and antibodies against myelin protein zero, whereas the role of the T cells remains largely unknown. We analyzed protein zero-specific B cells, as antigen-presenting cells, and their capacity to activate T helper cells. DESIGN AND METHODS We used a well-characterized monoclonal gammopathy of undetermined significance-derived B-cell line, TJ2, expressing anti-protein zero immunoglobulin M. The ability of TJ2 cells to bind, endocytose, process, and present protein zero was investigated by receptor-clustering and immunofluorescence. The activation of protein zero-specific autologous T cells was studied by measuring interleukin-2 and interferon-gamma with flow cytometry, immunobeads, and enzyme-linked immunospot assays. RESULTS Surface-receptor clustering and endocytosis of receptor-ligand (immunoglobulin M/protein zero) complexes were pronounced after exposure to protein zero. Naturally processed or synthetic protein zero peptide (194-208)-pulsed TJ2 cells significantly induced interleukin-2 secretion from autologous T cells compared to control antigen-pulsed cells (P<0.001). The numbers of interferon-gamma-producing T helper cells, including CD4(+)/CD8(+) cells, were also significantly increased (P=0.0152). Affinity-isolated naturally processed myelin peptides were potent interferon-gamma stimulators for autologous peripheral blood mononuclear cells, but not for control peripheral blood mononuclear cells. CONCLUSIONS We show for the first time that myelin protein zero is naturally processed in B cells from monoclonal gammopathy of undetermined significance of immunoglobulin M isotype, acting as aberrant antigen-presenting cells in activation of a patient's T helper cells. Our findings cast new light on the important role of autoreactive protein zero-specific B cells in the induction of the pathogenic T-cell responses found in nerve lesions of patients with monoclonal gammopathy of undetermined significance with peripheral neuropathy.
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Affiliation(s)
- Eva Hellqvist
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, SE-581 85 Linköping, Sweden
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McMaster ML, Kristinsson SY, Turesson I, Björkholm M, Landgren O. Novel aspects pertaining to the relationship of Waldenström's macroglobulinemia, IgM monoclonal gammopathy of undetermined significance, polyclonal gammopathy, and hypoglobulinemia. ACTA ACUST UNITED AC 2009; 9:19-22. [PMID: 19362963 DOI: 10.3816/clm.2009.n.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Waldenström's macroglobulinemia (WM) is associated with a precursor condition, monoclonal gammopathy of undetermined significance (MGUS) of immunoglobulin-M (IgM) type. The etiology of these conditions is unknown. Recent studies at the population level have provided new data regarding familial aggregation of these disorders and other B-cell malignancies. Studies of familial clusters of WM have demonstrated an increased frequency of IgM MGUS compared with the general population and have provided new data suggesting that the phenotypic spectrum might also include polyclonal gammopathy and hypoglobulinemia. While the preponderance of immunoglobulin abnormalities in relatives of WM cases involves IgM, other immunoglobulin types (IgG and IgA) might also be affected. Large collaborative studies are needed to confirm these findings, which present an opportunity to define the earliest lesion(s) in the WM oncogenic pathway.
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Affiliation(s)
- Mary L McMaster
- Genetic Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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Rossi F, Petrucci MT, Guffanti A, Marcheselli L, Rossi D, Callea V, Vincenzo F, De Muro M, Baraldi A, Villani O, Musto P, Bacigalupo A, Gaidano G, Avvisati G, Goldaniga M, Depaoli L, Baldini L. Proposal and validation of prognostic scoring systems for IgG and IgA monoclonal gammopathies of undetermined significance. Clin Cancer Res 2009; 15:4439-45. [PMID: 19509142 DOI: 10.1158/1078-0432.ccr-08-3150] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The presenting clinico-hematologic features of 1,283 patients with IgG and IgA monoclonal gammopathies of undetermined significance (MGUS) were correlated with the frequency of evolution into multiple myeloma (MM). EXPERIMENTAL DESIGN Two IgG MGUS populations were evaluated: a training sample (553 patients) and a test sample (378 patients); the IgA MGUS population consisted of 352 patients. RESULTS Forty-seven of the 553 training group patients and 22 of 378 test group IgG patients developed MM after a median follow-up of 6.7 and 3.6 years, respectively. Multivariate analysis showed that serum monoclonal component (MC) levels of < or =1.5 g/dL, the absence of light-chain proteinuria and normal serum polyclonal immunoglobulin levels defined a prognostically favorable subset of patients, and could be used to stratify the patients into three groups at different 10-year risk of evolution (hazard ratio, 1.0, 5.04, 11.2; P < 0.001). This scoring system was validated in the test sample. Thirty of the 352 IgA patients developed MM after a median follow-up of 4.8 years, and multivariate analysis showed that hemoglobin levels of <12.5 g/dL and reduced serum polyclonal immunoglobulin correlated with progression. A pooled statistical analysis of all of the patients confirmed the validity of Mayo Clinic risk model showing that IgA class, serum MC levels, and light-chain proteinuria are the most important variables correlated with disease progression. CONCLUSIONS Using simple variables, we validated a prognostic model for IgG MGUS. Among the IgA cases, the possible prognostic role of hemoglobin emerged in addition to a decrease in normal immunoglobulin levels.
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Affiliation(s)
- Francesca Rossi
- UO Ematologia 1/CTMO, Fondazione Ospedale Maggiore PoMaRe, Istituto di Ricovero e Cura a Carattere Scientifico, Università degli Studi, Italy
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AL amyloidosis associated with IgM paraproteinemia: clinical profile and treatment outcome. Blood 2008; 112:4009-16. [DOI: 10.1182/blood-2008-02-138156] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractAL amyloidosis associated with immunoglobulin M (IgM) paraproteinemia is rare. We report 103 consecutive such patients evaluated at the National Amyloidosis Centre (London, United Kingdom) between 1988 and 2006. Renal, cardiac, and lymph node amyloid was present in 53%, 35%, and 21% of patients, respectively, at presentation and 2 or more organs were involved in 54%. Seventy-three percent had an abnormal bone marrow infiltrate (lymphoid in 87%). The median IgM paraprotein was 8 g/L and serum free light chain (FLC) ratio was abnormal in 77 (88%) of 87. The abnormal FLC component was more than 100 mg/L in only 31% cases. Thirty-two percent achieved a partial hematologic response to treatment with no complete responders, and there appeared to be a greater response to combination regimens than single-agent oral alkylators (59% vs 20%, respectively; P = .003). Four achieved amyloidotic organ responses; organ function remained stable in 68%. None with lymph node involvement showed nodal improvement. Median overall survival was 49 months. AL amyloidosis with IgM paraproteinemia represents a distinctive subset of patients with AL amyloidosis who have a wider variety of underlying clonal disorders (often lymphoid) than AL in general, have low-level FLC abnormality, and should be treated with appropriately tailored chemotherapeutic regimens for the underlying clonal disorder.
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Kyle RA, Rajkumar SV. Criteria for diagnosis, staging, risk stratification and response assessment of multiple myeloma. Leukemia 2008; 23:3-9. [PMID: 18971951 DOI: 10.1038/leu.2008.291] [Citation(s) in RCA: 793] [Impact Index Per Article: 49.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
New systems have emerged for diagnosis, staging and response assessment in multiple myeloma (MM). The diagnostic and response criteria recommended are primarily derived from the International Myeloma Working Group, with certain updates and clarifications. The International Staging System is the current standard for staging of myeloma. A new risk stratification model is provided to specifically define high-risk patients who may benefit from novel therapeutic strategies. This paper provides the current criteria for diagnosis, staging, risk stratification and response assessment of MM.
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Affiliation(s)
- R A Kyle
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA.
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Koshiol J, Gridley G, Engels EA, McMaster ML, Landgren O. Chronic immune stimulation and subsequent Waldenström macroglobulinemia. ACTA ACUST UNITED AC 2008; 168:1903-9. [PMID: 18809818 DOI: 10.1001/archinternmed.2008.4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Certain autoimmune and infectious conditions are associated with increased risks of subtypes of non-Hodgkin lymphoma. A few previous studies suggest that chronic inflammation may particularly elevate risk of the distinct non-Hodgkin lymphoma subtype Waldenström macroglobulinemia (WM). METHODS We assessed WM risk in relation to a variety of chronic immune stimulatory conditions in 4 million US veterans. We identified 361 patients with WM with up to 27 years of follow-up. Using time-dependent Poisson regression, we estimated rate ratios (RRs) and 95% confidence intervals (CIs) for WM risk in relation to history of autoimmune diseases that typically have autoantibodies (with systemic or organ involvement) or do not have autoantibodies, infections, and allergies. All the models were adjusted for attained age, calendar year, race, number of hospital visits, and latency between study entry and exit. RESULTS The age-standardized incidence of WM was 0.34 per 100,000 person-years. Risk of WM was elevated in individuals with any previous autoimmune condition (RR, 2.23; 95% CI, 1.68-2.97), autoantibodies with systemic involvement (2.50; 1.55-4.02), or autoantibodies with organ involvement (2.30; 1.57-3.37). Risks of WM were also increased with hepatitis (RR, 3.39; 95% CI, 1.38-8.30), human immunodeficiency virus (12.05; 2.83-51.46), and rickettsiosis (3.35; 1.38-8.14). CONCLUSIONS In the largest investigation of WM risk factors to date, we found a 2- to 3-fold elevated risk of WM in persons with a personal history of autoimmune diseases with autoantibodies and notably elevated risks associated with hepatitis, human immunodeficiency virus, and rickettsiosis. These findings provide novel insights into the still unknown etiology of WM.
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Affiliation(s)
- Jill Koshiol
- Cancer Prevention Fellowship Program, Office of Preventive Oncology, and Division of Genetic Epidemiology Branch, National Cancer Institute, 6120 Executive Blvd, EPS 7003, MSC 7236, Bethesda, MD 20892-7236, USA.
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McMaster ML, Caporaso N. Waldenström macroglobulinaemia and IgM monoclonal gammopathy of undetermined significance: emerging understanding of a potential precursor condition. Br J Haematol 2008; 139:663-71. [PMID: 18021080 DOI: 10.1111/j.1365-2141.2007.06845.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Previously thought to be best described as a plasma cell disorder, Waldenström macroglobulinaemia (WM) is now understood to be a distinct clinicobiological entity. WM shares B-cell origin and certain other features with both chronic lymphocytic leukaemia (CLL) and multiple myeloma (MM). WM and CLL arise from B-cells at discrete stages in their maturation process, and MM arises from B-cells that have fully differentiated into plasma cells. While MM has a well-known precursor condition, monoclonal gammopathy of undetermined significance (MGUS), CLL and WM may also have associated precursor states, monoclonal B-cell lymphocytosis (MBL) and IgM MGUS, respectively. This review explores the features that link or distinguish these haematolymphoid malignancies, with special attention to emerging data regarding IgM MGUS and its unique relationship to WM, and identifies important gaps in our understanding of the putative precursor conditions, MBL and IgM MGUS.
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Affiliation(s)
- Mary L McMaster
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smouldering multiple myeloma: emphasis on risk factors for progression. Br J Haematol 2008; 139:730-43. [PMID: 18021088 DOI: 10.1111/j.1365-2141.2007.06873.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is characterized by a serum monoclonal protein <30 g/l, <10% plasma cells in the bone marrow, and absence of end-organ damage (CRAB-hypercalcaemia, renal insufficiency, anaemia, or bone lesions). MGUS is present in 3% of persons >50 years and in 5% >70 years of age. The risk of progression to multiple myeloma (MM) or a related disorder is 1% per year. Patients with risk factors consisting of an abnormal serum free light chain ratio, non-immunoglobulin G (IgG) MGUS, and an elevated serum M protein >/=15 g/l had a risk of progression at 20 years of 58%, compared with 37% with two risk factors present, 21% with one risk factor present, and 5% when none of the risk factors were present. Smouldering (asymptomatic) multiple myeloma is characterized by having a serum IgG or IgA monoclonal protein of 30 g/l or higher and/or 10% or more plasma cells in the bone marrow but no evidence of end-organ damage. The cumulative probability of progression to active MM or amyloidosis was 51% at 5 years, 66% at 10 years and 73% at 15 years; the median time to progression was 4.8 years.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Terrier B, Jaccard A, Harousseau JL, Delarue R, Tournilhac O, Hunault-Berger M, Hamidou M, Dantal J, Bernard M, Grosbois B, Morel P, Coiteux V, Gisserot O, Rodon P, Hot A, Elie C, Leblond V, Fermand JP, Fakhouri F. The clinical spectrum of IgM-related amyloidosis: a French nationwide retrospective study of 72 patients. Medicine (Baltimore) 2008; 87:99-109. [PMID: 18344807 DOI: 10.1097/md.0b13e31816c43b6] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Immunoglobulin M (IgM)-related amyloidosis remains a rare and little-known complication of monoclonal IgM-associated disorders. We sought to determine the clinical and laboratory presentation, response to treatment, and outcome of patients with IgM-related amyloidosis in the era of new therapeutic approaches. We conducted a retrospective study in 29 French centers to identify patients with monoclonal IgM and biopsy-proven amyloidosis; we reviewed patients' records and collected relevant clinical and laboratory data. We identified 72 patients with IgM-related amyloidosis. Systemic primary amyloidosis (AL) was present in 64, peritumoral AL in 5, and systemic secondary amyloidosis (AA) in 3 patients. A peculiar pattern of relatively frequent lymph node (31%) and lung (17%) involvement was noted in patients with systemic AL amyloidosis. Response to alkylating agents was poor, with a hematologic response in 37%, a complete remission in 0%, and an organ response in 21%. Response to hematopoietic stem cell transplantation showed a hematologic response in 100% with complete remission in 75% and an organ response in 75%. Purine analogs and rituximab induced a hematologic response in 73% and 60%, respectively, with complete remission in 9% and 0% and an organ response in 55% and 0%, respectively. In multivariate analysis, prognostic factors for survival were serum albumin level < or =3.5 g/dL (p = 0.018) and heart involvement (p = 0.0034). Further prospective studies are needed in patients with IgM-related amyloidosis, with special emphasis on treatment options: hematopoietic stem cell transplantation and purine analogs could represent the most effective therapies. The identification of adverse prognostic factors of survival could be useful for those managing and making treatment decisions for these patients.
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Affiliation(s)
- Benjamin Terrier
- From Service de Néphrologie et d'Hématologie (BT, RD, FF), and Service de Biostatistiques (CE), CHU Necker-Enfants Malades, Assistance Publique des Hôpitaux de Paris, Paris; Service d'Hématologie Clinique (AJ), Centre de Référence des Amyloses Primitives et des Autres Maladies de Dépô t d'Immunoglobuline, CHU, Limoges; Service d'Hématologie (JLH), Service de Médecine Interne (MH), and Service de Néphrologie (JD), CHU Hôtel-Dieu, Nantes; Service d'Hématologie (OT), CHU, Clermont-Ferrand; Service d'Hématologie (MHB), CHU, Angers; Service d'Hématologie (MB) and Service de Médecine Interne (BG), CHU, Rennes; Service d'Hématologie (PM), Hôpital, Lens; Service d'Hématologie (VC), CHRU Claude Huriez, Lille; Service d'Hématologie et Médecine Interne (OG), Hôpital Saint-Anne, Toulon; Service d'Hématologie (PR), Hôpital, Blois; Service de Médecine Interne (AH), CHU, Lyon; Service d'Hématologie (VL), CHU Pitié- Salpétrière, Paris; and Service d'Immuno-Hématologie (JPF), CHU Saint-Louis, Paris, France
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Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. Hematol Oncol Clin North Am 2008; 21:1093-113, ix. [PMID: 17996590 DOI: 10.1016/j.hoc.2007.08.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In 1978, the term "monoclonal gammopathy of undetermined significance" (MGUS) was introduced. MGUS is defined as a serum monoclonal (M) protein less than 3.0 g/dL; less than 10% plasma cells in the bone marrow, if done; little or no M protein in the urine; and absence of lytic bone lesions, anemia, hypercalcemia or renal insufficiency. This article discusses the recognition, prevalence, natural history, and progression of MGUS. Management of the disease is discussed along with its association with other disorders. Information on smoldering multiple myeloma is included.
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Affiliation(s)
- Robert A Kyle
- Division of Hematology, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Multiple myeloma: New staging systems for diagnosis, prognosis and response evaluation. Best Pract Res Clin Haematol 2007; 20:665-80. [DOI: 10.1016/j.beha.2007.10.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Eurelings M, Lokhorst HM, Notermans NC, Krijtenburg PJ, Kessel BV, Eleveld MJ, Bloem A, Wokke JH, Poot M, Buijs A. Cytogenetic aberrations in neuropathy associated with IgM monoclonal gammopathy. J Neurol Sci 2007; 260:124-31. [PMID: 17543994 DOI: 10.1016/j.jns.2007.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 04/12/2007] [Accepted: 04/16/2007] [Indexed: 11/19/2022]
Abstract
The occurrence and nature of cytogenetic aberrations in polyneuropathy associated with IgM monoclonal gammopathy was determined. Therefore, interphase fluorescence in situ hybridization (FISH) was applied in 22 patients with polyneuropathy associated with IgM monoclonal gammopathy, multiplex ligation-dependent probe amplification (MLPA) assay in 18 of these patients and genome-wide-array-based comparative genomic hybridization (CGH) in eight of these 18 patients. Four patients had 10-20% and one patient had 30% B cells with IgH rearrangements; one patient had additional loss of 14qter; one patient had amplification of 6p and loss of 6q. Cytogenetic aberrations may be found in one third of the patients with neuropathy associated with IgM monoclonal gammopathy and are mainly associated with indolent Waldenstrom's Macroglobulinemia.
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Affiliation(s)
- Marijke Eurelings
- Department of Neurology, the Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, The Netherlands.
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