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Tavares TS, da Costa AAS, Araújo ALD, de Souza LL, Pascoaloti MIM, Bernardes VF, Aguiar MCF, Vargas PA, Fonseca FP, Pontes HAR, Lopes MA, Santos-Silva AR, da Silva TA, Caldeira PC. Oral manifestations of amyloidosis and the diagnostic applicability of oral tissue biopsy. J Oral Pathol Med 2024; 53:61-69. [PMID: 38154788 DOI: 10.1111/jop.13504] [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: 10/10/2023] [Revised: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Amyloidosis exhibits a variable spectrum of systemic signs and oral manifestations that can be difficult to diagnose. This study aimed to characterize the clinical, demographic, and microscopic features of amyloidosis in the oral cavity. METHODS This collaborative study involved three Brazilian oral pathology centers and described cases with a confirmed diagnosis of amyloidosis on available oral tissue biopsies. Clinical data were obtained from medical records. H&E, Congo-red, and immunohistochemically stained slides were analyzed. RESULTS Twenty-six oral biopsies from 23 individuals (65.2% males; mean age: 59.6 years) were included. Oral involvement was the first sign of the disease in 67.0% of cases. Two patients had no clinical manifestation in the oral mucosa, although the histological analysis confirmed amyloid deposition. Amyloid deposits were distributed in perivascular (88.0%), periacinar and periductal (80.0%), perineurial (80.0%), endoneurial (33.3%), perimuscular (88.2%), intramuscular (94.1%), and subepithelial (35.3%) sites as well as around fat cells (100.0%). Mild/moderate inflammation was found in 65.4% of cases and 23.1% had giant cells. CONCLUSIONS Amyloid deposits were consistently found in oral tissues, exhibiting distinct deposition patterns. Oral biopsy is less invasive than internal organ biopsy and enables the reliable identification of amyloid deposits even in the absence of oral manifestations. These findings corroborate the relevance of oral biopsy for the diagnosis of amyloidosis.
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Affiliation(s)
- Thalita Soares Tavares
- Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | | | - Lucas Lacerda de Souza
- Oral Pathology Department, João de Barros Barreto University Hospital/Universidade Federal do Pará, Belém, PA, Brazil
| | - Maria Inês Mantuani Pascoaloti
- Department of Pathology, Biological Sciences Institute, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Vanessa Fátima Bernardes
- Department of Pathology, Biological Sciences Institute, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria Cássia Ferreira Aguiar
- Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Pablo Agustin Vargas
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas, Campinas, SP, Brazil
| | - Felipe Paiva Fonseca
- Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Hélder Antônio Rebelo Pontes
- Oral Pathology Department, João de Barros Barreto University Hospital/Universidade Federal do Pará, Belém, PA, Brazil
| | - Marcio Ajudarte Lopes
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas, Campinas, SP, Brazil
| | - Alan Roger Santos-Silva
- Oral Diagnosis Department, Piracicaba Dental School, University of Campinas, Campinas, SP, Brazil
| | - Tarcília Aparecida da Silva
- Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Patrícia Carlos Caldeira
- Department of Oral Pathology and Surgery, School of Dentistry, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Riehani A, Soubani AO. The spectrum of pulmonary amyloidosis. Respir Med 2023; 218:107407. [PMID: 37696313 DOI: 10.1016/j.rmed.2023.107407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 09/13/2023]
Abstract
Amyloidosis is a disease caused by misfolded proteins that deposit in the extracellular matrix as fibrils, resulting in the dysfunction of the involved organ. The lung is a common target of Amyloidosis, but pulmonary amyloidosis is uncommonly diagnosed since it is rarely symptomatic. Diagnosis of pulmonary amyloidosis is usually made in the setting of systemic amyloidosis, however in cases of localized pulmonary disease, surgical or transbronchial tissue biopsy might be indicated. Pulmonary amyloidosis can be present in a variety of discrete entities. Diffuse Alveolar septal amyloidosis is the most common type and is usually associated with systemic AL amyloidosis. Depending on the degree of the interstitial involvement, it may affect alveolar gas exchange and cause respiratory symptoms. Localized pulmonary Amyloidosis can present as Nodular, Cystic or Tracheobronchial Amyloidosis which may cause symptoms of airway obstruction and large airway stenosis. Pleural effusions, mediastinal lymphadenopathy and pulmonary hypertension has also been reported. Treatment of all types of pulmonary amyloidosis depends on the type of precursor protein, organ involvement and distribution of the disease. Most of the cases are asymptomatic and require only close monitoring. Diffuse alveolar septal amyloidosis treatment follows the treatment of underlying systemic amyloidosis. Tracheobronchial amyloidosis is usually treated with bronchoscopic interventions including debulking and stenting or with external beam radiation. Long-term prognosis of pulmonary amyloidosis usually depends on the type of lung involvement and other organ function.
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Affiliation(s)
- Anas Riehani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA.
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Lacouture Fierro JA, Ribero Vargas DA, Sánchez Cano J, Gaviria Jaramillo LM, Perilla Suarez OG, Galvez Cárdenas KM, Ospina Ospina S. Clinical characterization and outcomes of a cohort of colombian patients with AL Amyloidosis. Colomb Med (Cali) 2023; 54:e2025667. [PMID: 38107838 PMCID: PMC10723764 DOI: 10.25100/cm.v54i3.5667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/30/2023] [Accepted: 09/24/2023] [Indexed: 12/19/2023] Open
Abstract
Background Amyloid light chain (AL) amyloidosis is characterized by amyloid fibril deposition derived from monoclonal immunoglobulin light chains, resulting in multiorgan dysfunction. Limited data exist on the clinical features of AL amyloidosis. Objective This study aims to describe the clinical characteristics, treatments, and outcomes in Colombian patients with AL amyloidosis. Methods A retrospective descriptive study was conducted at three high-complexity centers in Medellín, Colombia. Adults with AL amyloidosis diagnosed between 2012 and 2022 were included. Clinical, laboratory, histological, treatment, and survival data were analyzed. Results The study included 63 patients. Renal involvement was most prevalent (66%), followed by cardiac involvement (61%). Multiorgan involvement occurred in 61% of patients. Amyloid deposition was most commonly detected in renal biopsy (40%). Bortezomib-based therapy was used in 68%, and 23.8% received high-dose chemotherapy with autologous hematopoietic stem cell transplantation (HDCT-ASCT). Hematological response was observed in 95% of patients with available data. Cardiac and renal organ responses were 15% and 14%, respectively. Median overall survival was 45.1 months (95% CI: 22.2-63.8). In multivariate analysis, cardiac involvement was significantly associated with inferior overall survival (HR 3.27; 95% CI: 1.23-8.73; p=0.018), HDCT-ASCT had a non-significant trend towards improved overall survival (HR 0.25; 95% CI: 0.06-1.09; p=0.065). Conclusions In this study of Colombian patients with AL amyloidosis, renal involvement was more frequent than cardiac involvement. Overall survival and multiorgan involvement were consistent with data from other regions of the world. Multivariate analysis identified cardiac involvement and HDCT-AHCT as possible prognostic factors.
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Affiliation(s)
- Jorge Andrés Lacouture Fierro
- Hospital San Vicente Fundación Rionegro , Departamento de Hematología, Rionegro, Colombia
- Universidad de Antioquia, Sección de Hematología Clínica, Departamento de Medicina interna, Facultad de Medicina, Medellín, Colombia
| | - Daniel Andrés Ribero Vargas
- Universidad de Antioquia, Facultad de Medicina Departamento de Medicina interna, Medellín, Colombia
- Hospital Alma Mater de Antioquia, Departamento de Medicina Interna, Medellín, Colombia
| | | | - Lina Maria Gaviria Jaramillo
- Universidad de Antioquia, Sección de Hematología Clínica, Departamento de Medicina interna, Facultad de Medicina, Medellín, Colombia
- Hospital San Vicente Fundación Medellín, Departamento de Hematología, Medellín, Colombia
| | - Oliver Gerardo Perilla Suarez
- Universidad de Antioquia, Sección de Hematología Clínica, Departamento de Medicina interna, Facultad de Medicina, Medellín, Colombia
- Hospital San Vicente Fundación Medellín, Departamento de Hematología, Medellín, Colombia
| | | | - Sigifredo Ospina Ospina
- Universidad de Antioquia, Instituto de Investigaciones Médicas, Facultad de Medicina, Medellín, Colombia
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Karam S, Haidous M, Royal V, Leung N. Renal AA amyloidosis: presentation, diagnosis, and current therapeutic options: a review. Kidney Int 2023; 103:473-484. [PMID: 36502873 DOI: 10.1016/j.kint.2022.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/13/2022]
Abstract
Amyloid A amyloidosis is thought to be the second most common form of systemic amyloidosis behind amyloidosis secondary to monoclonal Ig. It is the result of deposition of insoluble fibrils in the extracellular space of tissues and organs derived from the precursor protein serum amyloid A, an acute phase reactant synthesized excessively in the setting of chronic inflammation. The kidney is the most frequent organ involved. Most patients present with proteinuria and kidney failure. The diagnosis is made through tissue biopsy with involvement of the glomeruli in most cases, but also often of the vessels and the tubulointerstitial compartment. The treatment usually targets the underlying etiology and consists increasingly of blocking the inflammatory cascade of cytokines with interleukin-1 inhibitors, interleukin-6 inhibitors, and tumor necrosis factor-α inhibitors to reduce serum amyloid A protein formation. This strategy has also shown efficacy in cases where an underlying etiology cannot be readily identified and has significantly improved the prognosis of this entity. In addition, there has been increased interest at developing effective therapies able to clear amyloid deposits from tissues, albeit with mitigated results so far.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Mohamad Haidous
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Quebec, Canada
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Diagnosis and Treatment of AL Amyloidosis. Drugs 2023; 83:203-216. [PMID: 36652193 DOI: 10.1007/s40265-022-01830-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Systemic light chain (AL) amyloidosis is caused by an usually small B cell clone that produces a toxic light chain forming amyloid deposits in tissue. The heart and kidney are the major organs affected, but all others, with the exception of the CNS, can be involved. The disease is rapidly progressive, and it is still diagnosed late. Screening programs in patients followed by hematologists for plasma cell dyscrasias should be considered. The diagnosis requires demonstration in a tissue biopsy of amyloid deposits formed by immunoglobulin light chains. The workup of patients with AL amyloidosis requires adequate technology and expertise, and patients should be referred to specialized centers whenever possible. Stagings are based on cardiac and renal biomarkers and guides the choice of treatment. The combination of daratumumab, cyclophosphamide, bortezomib and dexamethasone (dara-CyBorD) is the current standard of care. Autologous stem cell transplant is performed in eligible patients, especially those who do not attain a satisfactory response to dara-CyBorD. Passive immunotherapy targeting the amyloid deposits combined with chemo-/immune-therapy targeting the amyloid clone is currently being tested in controlled clinical trials. Response to therapy is assessed based on validated criteria. Profound hematologic response is the early goal of treatment and should be accompanied over time by deepening organ response. Many relapsed/refractory patients are also treated with daratumumab combination, but novel regimens will be needed to rescue daratumumab-exposed subjects. Immunomodulatory drugs are the current cornerstone of rescue therapy, while immunotherapy targeting B-cell maturation antigen and inhibitors of Bcl-2 are promising alternatives.
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Jensen CE, Byku M, Hladik GA, Jain K, Traub RE, Tuchman SA. Supportive Care and Symptom Management for Patients With Immunoglobulin Light Chain (AL) Amyloidosis. Front Oncol 2022; 12:907584. [PMID: 35814419 PMCID: PMC9259942 DOI: 10.3389/fonc.2022.907584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022] Open
Abstract
Immunoglobulin light chain (AL) amyloidosis is a disorder of clonal plasma cells characterized by deposition of amyloid fibrils in a variety of tissues, leading to end-organ injury. Renal or cardiac involvement is most common, though any organ outside the central nervous system can develop amyloid deposition, and symptomatic presentations may consequently vary. The variability and subtlety of initial clinical presentations may contribute to delayed diagnoses, and organ involvement is often quite advanced and symptomatic by the time a diagnosis is established. Additionally, while organ function can improve with plasma-cell-directed therapy, such improvement lags behind hematologic response. Consequently, highly effective supportive care, including symptom management, is essential to improve quality of life and to maximize both tolerance of therapy and likelihood of survival. Considering the systemic nature of the disease, close collaboration between clinicians is essential for effective management.
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Affiliation(s)
- Christopher E. Jensen
- Division of Hematology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC, United States
| | - Mirnela Byku
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Gerald A. Hladik
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Koyal Jain
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Rebecca E. Traub
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
| | - Sascha A. Tuchman
- Division of Hematology, University of North Carolina School of Medicine, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, United States
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Bailleux S, Collins P, Nikkels AF. The Relevance of Skin Biopsies in General Internal Medicine: Facts and Myths. Dermatol Ther (Heidelb) 2022; 12:1103-1119. [PMID: 35430724 PMCID: PMC9110592 DOI: 10.1007/s13555-022-00717-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Non-dermatology medical specialties may refer patients for skin biopsies, searching for a particular diagnosis. However, the diagnostic impact of the skin biopsy is not clearly established. This article aims to assess the indications for, and evaluate the clinical relevance of, skin biopsies in non-dermatology medical specialties. Methods A questionnaire was sent to 23 non-dermatology specialty departments in a university medical center, requesting a list of indications for skin biopsies, as well as to 10 staff dermatologists to collect the indications of skin biopsies requested by non-dermatology specialties. Once the indications were collected, a literature search was performed to evaluate their clinical value and relevance. Results Eleven non-dermatology specialties provided a list of skin biopsy indications, to which staff dermatologists added seven more indications. A literature search revealed evidence-based medicine data for six diseases, that is, amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, and chronic graft-versus-host disease. Results were questionable concerning infectious endocarditis, acute graft-versus-host-disease, and the lupus band test. Skin biopsy were not evidenced as useful for the diagnosis of calciphylaxis, systemic scleroderma, Behçet’s disease, or hypermobile Ehlers–Danlos syndrome. For the diagnosis of Alport’s syndrome, pseudoxanthoma elasticum, and vascular Ehlers–Danlos syndrome, skin biopsy is currently outperformed by genetic analyses. For diagnoses such as Henoch–Schönlein purpura and Sjögren’s syndrome, skin biopsy represents an additional item among other diagnostic criteria. Conclusion The usefulness of skin biopsy as requested by non-dermatology specialties is only evidenced for amyloidosis, peripheral autonomic neuropathy, Sneddon’s syndrome, intravascular lymphoma, sarcoidosis, chronic graft-versus-host-disease, Henoch–Schönlein purpura, and Sjögren’s syndrome.
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Affiliation(s)
- Sophie Bailleux
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium
| | - Patrick Collins
- Department of Dermatopathology, University Hospital Centre, CHU du Sart Tilman, Liège, Belgium
| | - Arjen F Nikkels
- Department of Dermatology, University Hospital Centre, CHU du Sart Tilman, University of Liège, 4000, Liège, Belgium.
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Abstract
Amyloidosis constitutes a large spectrum of diseases characterized by an extracellular deposition of a fibrillar aggregate, generating insoluble and toxic amasses that may be deposited in tissues in bundles with an abnormal cross-β-sheet conformation, known as amyloid. Amyloid may lead to a cell damage and an impairment of organ function. Several different proteins are recognized as able to produce amyloid fibrils with a different tissue tropism related to the molecular structure. The deposition of amyloid may occur as a consequence of the presence of an abnormal protein, caused by high plasma levels of a normal protein, or as a result of the aging process along with some environmental factors. Although amyloidosis is rare, amyloid deposits play a role in several conditions as degenerative diseases. Thus, the development of antiamyloid curative treatments may be a rational approach to treat neurodegenerative conditions like Alzheimer's disease in the future. Nowadays, novel treatment options are currently refined through controlled trials, as new drug targets and different therapeutic approaches have been identified and validated through modern advances in basic research. Fibril formation stabilizers, proteasome inhibitors, and immunotherapy revealed promising results in improving the outcomes of patients with systemic amyloidosis, and these novel algorithms will be effectively combined with current treatments based on chemotherapeutic regimens. The aim of this review is to provide an update on diagnosis and treatment for systemic amyloidosis.
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Obici L, Adams D. Acquired and inherited amyloidosis: Knowledge driving patients' care. J Peripher Nerv Syst 2021; 25:85-101. [PMID: 32378274 DOI: 10.1111/jns.12381] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/19/2022]
Abstract
Until recently, systemic amyloidoses were regarded as ineluctably disabling and life-threatening diseases. However, this field has witnessed major advances in the last decade, with significant improvements in therapeutic options and in the availability of accurate and non-invasive diagnostic tools. Outstanding progress includes unprecedented hematological response rates provided by risk-adapted regimens in light chain (AL) amyloidosis and the approval of innovative pharmacological agents for both hereditary and wild-type transthyretin amyloidosis (ATTR). Moreover, the incidence of secondary (AA) amyloidosis has continuously reduced, reflecting advances in therapeutics and overall management of several chronic inflammatory diseases. The identification and validation of novel therapeutic targets has grounded on a better knowledge of key molecular events underlying protein misfolding and aggregation and on the increasing availability of diagnostic, prognostic and predictive markers of organ damage and response to treatment. In this review, we focus on these recent advancements and discuss how they are translating into improved outcomes. Neurological involvement dominates the clinical picture in transthyretin and gelsolin inherited amyloidosis and has a significant impact on disease course and management in all patients. Neurologists, therefore, play a major role in improving patients' journey to diagnosis and in providing early access to treatment in order to prevent significant disability and extend survival.
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Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - David Adams
- National Reference Center for Familial Amyloid Polyneuropathy and Other Rare Neuropathies, APHP, Université Paris Saclay, INSERM U1195, Le Kremlin Bicêtre, France
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Karam S, Leung N. Renal Involvement in Systemic Amyloidosis Caused by Monoclonal Immunoglobulins. Hematol Oncol Clin North Am 2020; 34:1069-1079. [PMID: 33099424 DOI: 10.1016/j.hoc.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Kidney involvement in immunoglobulin-related amyloidosis (AIg) is common. Although patients with renal-limited AIg tend not to have the high mortality that patients with cardiac amyloidosis have, they do experience significant morbidity and impact on quality of life. The complexity of the pathogenesis remains incompletely understood. Models have been established to prognosticate and assess for the response to therapy. Patients with advanced renal impairment from immunoglobulin light chain amyloidosis still have poor renal prognosis, and better therapy is needed in order to preserve kidney function. Patients who develop end-stage renal disease can undergo renal replacement therapy with kidney transplantation.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, Saint George Hospital University Medical Center, PO Box 166 378 Achrafieh, Beirut 11 00 2807, Lebanon. https://twitter.com/sabinekaram6
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Basset M, Nuvolone M, Palladini G, Merlini G. Novel challenges in the management of immunoglobulin light chain amyloidosis: from the bench to the bedside. Expert Rev Hematol 2020; 13:1003-1015. [PMID: 32721177 DOI: 10.1080/17474086.2020.1803060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Immunoglobulin light chain (AL) amyloidosis is one of the most frequent systemic amyloidosis in Western countries. It is caused by a B-cell clone producing a misfolded light chain (LC) that deposits in organs. AREAS COVERED The review examines recent findings on pathophysiology and clinical management of AL amyloidosis. It contains an update on the recent hot topics as novel therapeutic approaches, definition of relapse, and hematologic response assessment. To review literature on AL amyloidosis, a bibliographic search was performed using PubMed. EXPERT OPINION Due to the proteotoxicity of amyloidogenic LCs, the therapeutic goal is a rapid and profound decrease in their concentration. The standard treatment is a risk-adapted chemotherapy targeting the B-cell clone. Novel, promising drugs, as daratumumab, are currently under evaluation in newly-diagnosed and relapsed/refractory patients. New sensitive techniques, as mass spectrometry approach and bone marrow minimal residual disease assessment, are available to evaluate depth of response. After first-line therapy, increase in LC concentration may precede worsening of organ dysfunction and should be considered carefully. Further clarification of molecular mechanisms of the disease are shedding light on new possible therapeutic targets. Innovative treatment strategies and novel technologies will improve our ability to treat AL amyloidosis, preventing organ deterioration.
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Affiliation(s)
- Marco Basset
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
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Abstract
PURPOSE Amyloidosis represents an increasingly recognized but still frequently missed cause of heart failure. In the light of many effective therapies for light chain (AL) amyloidosis and promising new treatment options for transthyretin (ATTR) amyloidosis, awareness among caregivers needs to be raised to screen for amyloidosis as an important and potentially treatable differential diagnosis. This review outlines the diversity of cardiac amyloidosis, its relation to heart failure, the diagnostic algorithm, and therapeutic considerations that should be applied depending on the underlying type of amyloidosis. RECENT FINDINGS Non-biopsy diagnosis is feasible in ATTR amyloidosis in the absence of a monoclonal component resulting in higher detection rates of cardiac ATTR amyloidosis. Biomarker-guided staging systems have been updated to facilitate risk stratification according to currently available biomarkers independent of regional differences, but have not yet prospectively been tested. Novel therapies for hereditary and wild-type ATTR amyloidosis are increasingly available. The complex treatment options for AL amyloidosis are improving continuously, resulting in better survival and quality of life. Mortality in advanced cardiac amyloidosis remains high, underlining the importance of early diagnosis and treatment initiation. Cardiac amyloidosis is characterized by etiologic and clinical heterogeneity resulting in a frequently delayed diagnosis and an inappropriately high mortality risk. New treatment options for this hitherto partially untreatable condition have become and will become available, but raise challenges regarding their implementation. Referral to specialized centers providing access to extensive and targeted diagnostic investigations and treatment initiation may help to face these challenges.
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Doe-Williams S, Hixson LJ, Pfeiffer DC. Massive Hepatomegaly Secondary to Amyloidosis with Normal Liver Chemistries. Case Rep Gastroenterol 2020; 14:271-278. [PMID: 32518538 PMCID: PMC7265701 DOI: 10.1159/000507612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/30/2020] [Indexed: 11/19/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is a disease of misfolded, fibrous proteins, either kappa or lambda subtype, that can be deposited into one or more organs, caused by a proliferation of plasma cells. The liver is uncommonly the main organ system affected and rarely the only organ affected by amyloid deposition. With hepatic involvement, the most common presenting findings are hepatomegaly and elevation of serum alkaline phosphatase. We report a case of a 50-year-old male who presented to our gastroenterology clinic with marked hepatomegaly secondary to hepatic amyloidosis, in concert with bone marrow involvement and nephrotic syndrome. Biopsies in conjunction with Congo red staining demonstrated 95% replacement of hepatic structure and 80% replacement of bone marrow with amyloid deposition. Despite these findings, liver chemistries, renal function, and blood count were normal. Our case presents not only the rare finding of primary hepatic amyloidosis but also an atypical presentation of this disorder. Although rare, AL amyloidosis should be in a differential diagnosis of any patient who presents with unexplained hepatomegaly, nephrotic-range proteinuria, heart failure with preserved ejection fraction, fatigue, weight loss or a history of monoclonal gammopathy of undetermined significance.
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Affiliation(s)
- Sarah Doe-Williams
- WWAMI Medical Education Program, University of Washington School of Medicine and the University of Idaho, Moscow, Idaho, USA
| | - Lee J Hixson
- St Joseph Regional Medical Center, Lewiston, Idaho, USA
| | - David C Pfeiffer
- WWAMI Medical Education Program and Department of Biological Sciences, University of Idaho, Moscow, Idaho, USA
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Ihne S, Morbach C, Sommer C, Geier A, Knop S, Störk S. Amyloidosis-the Diagnosis and Treatment of an Underdiagnosed Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:159-166. [PMID: 32295695 DOI: 10.3238/arztebl.2020.0159] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 08/25/2019] [Accepted: 12/12/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Systemic amyloidosis is a multi-system disease caused by fibrillary protein deposition with ensuing dysfunction of the affected organ systems. Its diagnosis is often delayed because the manifestations of the disease are variable and non-specific. Its main forms are light chain (AL) amyloidosis and transthyretinrelated ATTR amyloidosis, which, in turn, has both a sporadic subtype (wildtype, ATTRwt) and a hereditary subtype (mutated, ATTRv). METHODS This review is based on pertinent publications that were retrieved by a selective search in PubMed covering the years 2005 to 2019. RESULTS No robust epidemiological figures are available for Germany to date. Both AL amyloidosis and hereditary ATTR amyloidosis are rare diseases, but the prev - alence of ATTRwt amyloidosis is markedly underestimated. The diagnostic algorithm is complex and generally requires histological confirmation of the diagnosis. Only cardiac ATTR amyloidosis can be diagnosed non-invasively with bone scintigraphy once a monoclonal gammopathy has been excluded. AL amyloidosis can be considered a complication of a plasma cell dyscrasia and treated with reference to patterns applied in multiple myeloma. Despite the availability of causally directed treatment, it has not yet been possible to reduce the mortality of advanced cardiac AL amyloidosis. Three drugs (tafamidis, patisiran, and inotersen) are now available to treat grade 1 or 2 polyneuropathy in ATTRv amyloidosis, and further agents are now being tested in clinical trials. It is expected that tafamidis will soon be approved in Germany for the treatment of cardiac ATTR amyloidosis. CONCLUSION The diagnosis of amyloidosis is difficult because of its highly varied presentation. In case of clinical suspicion, a rapid, targeted diagnostic evaluation and subsequent initiation of treatment should be performed in a specialized center. When the new drugs to treat amyloidosis become commercially available, their use and effects should be documented in nationwide registries.
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Affiliation(s)
- Sandra Ihne
- Interdisciplinary Amyloidosis Center of Northern Bavaria, University Hospital Würzburg, Germany; Medical Clinic and Policlinic II, Dept. of Hemtatology, University Hospital Würzburg, Germany; Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Germany; Medical Clinic and Policlinic I, Dept. of Cardiology, University Hospital Würzburg, Germany; Department of Neurology, University Hospital Würzburg, Germany; Medical Clinic and Policlinic II, Dept. of Hepatology, University Hospital Würzburg, Germany
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15
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Latif A, Lateef N, Razzaq F, Kapoor V, Ahsan MJ, Ashfaq M, Iftikhar A, Anwer F, Holmberg M, William P. Fundamentals of Light Chain Cardiac Amyloidosis: A Focused Review. Cardiovasc Hematol Disord Drug Targets 2020; 20:274-283. [PMID: 33256586 DOI: 10.2174/1871529x20666201130110036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 06/12/2023]
Abstract
The estimated prevalence of AL CA in the US is approximately 8-12 cases per million. Almost 30-50% diagnosed cases of AL amyloid in the US have multisystem involvement, including cardiac involvement. Even with the availability of advanced diagnostic testing and novel therapies, prognosis remains poor. It is overlooked as a cause of heart failure with preserved ejection fraction leading to a delay in diagnosis when management options are limited and associated with poor survival outcomes. Therefore, the education of physicians is needed to ensure that it would be highly considered as a differential diagnosis. The purpose of this manuscript is to review the advances in the diagnosis and management of cardiac amyloidosis with the aim of educating colleagues who provide care in the primary care setting. We have summarized the pathogenesis of amyloidosis, its association with plasma cell dyscrasias, novel diagnostic and surveillance approaches including echocardiography, cardiovascular magnetic resonance imaging, histopathologic techniques, systemic biomarkers, and advanced treatment approaches including supportive symptomatic management and standard of care chemotherapy targeting the amyloid deposits. Given the overall poor prognosis of amyloidosis, we have also discussed the role of palliative and hospice care.
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Affiliation(s)
- Azka Latif
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Noman Lateef
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Faryal Razzaq
- Foundation University Medical College, Islamabad, Pakistan
| | - Vikas Kapoor
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Muhammad J Ahsan
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Muhammad Ashfaq
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Ahmad Iftikhar
- University of Arizona, Tucson, Arizona, AZ 85721, United States
| | - Faiz Anwer
- Cleveland Clinic, Cleveland, OH, United States
| | - Mark Holmberg
- Creighton University Medical Center, Omaha, Nebraska, NE, 68178, United States
| | - Preethi William
- University of Arizona, Tucson, Arizona, AZ 85721, United States
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16
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Hwa YL, Fogaren T, Sams A, Faller DV, Stull DM, Thuenemann S, Mendelson L. Immunoglobulin Light-Chain Amyloidosis: Clinical Presentations and Diagnostic Approach. J Adv Pract Oncol 2019; 10:470-481. [PMID: 33457060 PMCID: PMC7779572 DOI: 10.6004/jadpro.2019.10.5.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Systemic immunoglobulin light-chain (AL) amyloidosis is a rare disorder arising from a plasma cell clone that produces misfolded immunoglobulin light chains, which are deposited in various tissues and organs as amyloid fibrils. Signs and symptoms are typically vague and overlap with those arising from other common diseases; consequently, diagnosis of AL amyloidosis is challenging for clinicians. Substantial delays between onset of symptoms and diagnosis are common, and result in poorer outcomes, particularly in patients with cardiac AL amyloidosis and others who develop advanced organ dysfunction. With the need to identify AL amyloidosis as early as possible, it is important for health-care practitioners, including advanced practice clinicians and nurses, to be aware of the hallmark presenting signs and symptoms, as well as the latest practice for evaluation and diagnosis. Increased awareness of signs and symptoms associated with AL amyloidosis, particularly relating to the most frequently involved organs, the heart and kidneys, represents an opportunity for achieving earlier diagnosis. Here we review these issues in AL amyloidosis, summarize the key presenting symptoms that clinicians need to be alert to, and discuss the latest diagnostic tests, with the aim of expediting patient identification and diagnosis with the goal of improving patient outcomes.
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Affiliation(s)
- Yi L Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Teresa Fogaren
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Allison Sams
- Division of Hematology-Oncology, Outpatient Multiple Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Douglas V Faller
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Dawn M Stull
- Global Medical Affairs Oncology, Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Sara Thuenemann
- Global Medical Affairs Oncology, Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts
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17
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Affiliation(s)
- Christopher Strouse
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
| | - Alexandros Briasoulis
- Cardiomyopathy Section, Cardiology Division, University of Iowa, Iowa City, Iowa, USA
| | - Rafael Fonseca
- Bone Marrow Transplant Program, Mayo Clinic, Phoenix, Arizona, USA
| | - Yogesh Jethava
- Department of Internal Medicine, Division of Hematology, Oncology, and Blood and Marrow Transplantation, University of Iowa, Iowa City, IA, USA
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18
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Kircher M, Ihne S, Brumberg J, Morbach C, Knop S, Kortüm KM, Störk S, Buck AK, Reiter T, Bauer WR, Lapa C. Detection of cardiac amyloidosis with 18F-Florbetaben-PET/CT in comparison to echocardiography, cardiac MRI and DPD-scintigraphy. Eur J Nucl Med Mol Imaging 2019; 46:1407-1416. [PMID: 30798427 DOI: 10.1007/s00259-019-04290-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/08/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Cardiac amyloidosis (CA) is a rare cause of heart failure with frequently delayed diagnosis, because specific early signs or symptoms are missing. Recently, direct amyloid imaging using positron emission tomography/computed tomography (PET/CT) has emerged. The aim of this study was to examine the performance of 18F-florbetaben-PET/CT in detection of CA, and compare it to echocardiography (echo), cardiac MRI (CMR) and scintigraphy. Additionally, the use of 18F-florbetaben-PET/CT for quantification of amyloid burden and monitoring of treatment response was assessed. METHODS Twenty-two patients with proven (n = 5) or clinical suspicion (n = 17) of CA underwent 18F-florbetaben-PET/CT for diagnostic work-up. Qualitative and quantitative assessment including calculation of myocardial tracer retention (MTR) was performed, and compared to echo (n = 20), CMR (n = 16), scintigraphy (n = 16) and serologic biomarkers (NT-proBNP, cTnT, free light chains). In four patients, follow-up PET/CT was available (after treatment initiation, n = 3; surveillance, n = 1). RESULTS PET demonstrated myocardial 18F-florbetaben retention consistent with CA in 14/22 patients. Suspicion of CA was subsequently dropped in all eight PET-negative patients. Amyloid subtypes showed characteristic retention patterns (AL > AA > ATTR; all p < 0.005). MTR correlated with morphologic and functional parameters, as measured by CMR and echo (all r| > 0.47|, all p < 0.05), but not with cardiac biomarkers. Changes in MTR from baseline to follow-up corresponded well to treatment response, as assessed by cardiac biomarkers and performance status. CONCLUSIONS Imaging of cardiac amyloidosis (CA) with 18F-florbetaben-PET/CT is feasible and might be useful in differentiating CA subtypes.
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Affiliation(s)
- Malte Kircher
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany.,Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany
| | - Sandra Ihne
- Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Department of Internal Medicine II, Hemato-Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Joachim Brumberg
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
| | - Stefan Knop
- Department of Internal Medicine II, Hemato-Oncology, University Hospital Würzburg, Würzburg, Germany
| | - K Martin Kortüm
- Department of Internal Medicine II, Hemato-Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
| | - Andreas K Buck
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
| | - Theresa Reiter
- Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany.
| | - Wolfgang R Bauer
- Department of Internal Medicine I, Cardiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
| | - Constantin Lapa
- Department of Nuclear Medicine, University Hospital Würzburg, Oberdürrbacher Str. 6, 97078, Würzburg, Germany
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19
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Nuvolone M, Milani P, Palladini G, Merlini G. Management of the elderly patient with AL amyloidosis. Eur J Intern Med 2018; 58:48-56. [PMID: 29801808 DOI: 10.1016/j.ejim.2018.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/04/2018] [Indexed: 12/25/2022]
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is an aging-associated protein misfolding and deposition disease. This condition is caused by a small and otherwise indolent plasma cell (or B cell) clone secreting an unstable circulating light chain, which misfolds and deposits as amyloid fibrils possibly leading to progressive dysfunction of affected organs. AL amyloidosis can occur in the typical setting of other, rarer forms of systemic amyloidosis and can mimic other more prevalent conditions of the elderly. Therefore, its diagnosis requires a high degree of clinical suspicion and reliable diagnostic tools for accurate amyloid typing, available at specialized referral centers. In AL amyloidosis, frailty is dictated by the type and severity of organ involvement, with heart involvement being the main determinant of morbidity and mortality. Still, given a similar disease stage, elderly patients with AL amyloidosis are often an even frailer group, due to significant comorbidities, associated disability and polypharmacotherapy, socioeconomic restrictions, and limited access to clinical trials. Recent improvements in the use of biomarkers for early diagnosis, risk stratification and response monitoring, the flourishing of novel, effective anti-plasma cell therapies developed against multiple myeloma and adapted to treat AL amyloidosis, and possibly the introduction of anti-amyloid therapies are rapidly changing the clinical management of this disease and are reflected by improved outcomes. Of note, hematologic and organ responses in elderly patients with AL amyloidosis do translate in better outcome, advocating the importance of treating these patients and striving for a rapid response to therapy also in this challenging clinical setting.
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Affiliation(s)
- Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Italy.
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20
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Lecadet A, Bachmeyer C, Buob D, Cez A, Georgin-Lavialle S. Minor salivary gland biopsy is more effective than normal appearing skin biopsy for amyloid detection in systemic amyloidosis: A prospective monocentric study. Eur J Intern Med 2018; 57:e20-e21. [PMID: 30076089 DOI: 10.1016/j.ejim.2018.07.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/27/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Aude Lecadet
- Service de Médecine interne, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Hôpital Tenon (AP-HP), 75020 Paris, France
| | - Claude Bachmeyer
- Service de Médecine interne, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Hôpital Tenon (AP-HP), 75020 Paris, France.
| | - David Buob
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon (AP-HP), 75020 Paris, France
| | - Alexandre Cez
- Service de Néphrologie, Hôpital Tenon (APHP), 75020 Paris, France
| | - Sophie Georgin-Lavialle
- Service de Médecine interne, Centre de référence des maladies auto-inflammatoires et des amyloses d'origine inflammatoire (CEREMAIA), Hôpital Tenon (AP-HP), 75020 Paris, France
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21
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European myeloma network recommendations on diagnosis and management of patients with rare plasma cell dyscrasias. Leukemia 2018; 32:1883-1898. [DOI: 10.1038/s41375-018-0209-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/28/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023]
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22
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Milani P, Merlini G, Palladini G. Light Chain Amyloidosis. Mediterr J Hematol Infect Dis 2018; 10:e2018022. [PMID: 29531659 PMCID: PMC5841939 DOI: 10.4084/mjhid.2018.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/05/2018] [Indexed: 01/01/2023] Open
Abstract
Light chain (AL) amyloidosis is caused by a usually small plasma-cell clone that is able to produce the amyloidogenic light chains. They are able to misfold and aggregate, deposit in tissues in the form of amyloid fibrils and lead to irreversible organ dysfunction and eventually death if treatment is late or ineffective. Cardiac damage is the most important prognostic determinant. The risk of dialysis is predicted by the severity of renal involvement, defined by the baseline proteinuria and glomerular filtration rate, and by the response to therapy. The specific treatment is chemotherapy targeting the underlying plasma-cell clone. It needs to be risk-adapted, according to the severity of cardiac and/or multi-organ involvement. Autologous stem cell transplant (preceded by induction and/or followed by consolidation with bortezomib-based regimens) can be considered for low-risk patients (~20%). Bortezomib combined with alkylators is used in the majority of intermediate-risk patients, and with possible dose escalation in high-risk subjects. Novel, powerful anti-plasma cell agents were investigated in the relapsed/refractory setting, and are being moved to upfront therapy in clinical trials. In addition, the use of novel approaches based on antibodies targeting the amyloid deposits or small molecules interfering with the amyloidogenic process gave promising results in preliminary studies. Some of them are under evaluation in controlled trials. These molecules will probably add powerful complements to standard chemotherapy. The understanding of the specific molecular mechanisms of cardiac damage and the characteristics of the amyloidogenic clone are unveiling novel potential treatment approaches, moving towards a cure for this dreadful disease.
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Affiliation(s)
- Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo" and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo" and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo" and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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23
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Shimazaki C, Hata H, Iida S, Ueda M, Katoh N, Sekijima Y, Ikeda S, Yazaki M, Fukushima W, Ando Y. Nationwide Survey of 741 Patients with Systemic Amyloid Light-chain Amyloidosis in Japan. Intern Med 2018; 57:181-187. [PMID: 29093404 PMCID: PMC5820034 DOI: 10.2169/internalmedicine.9206-17] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objective To retrospectively investigate the clinical manifestations of systemic amyloid light-chain (AL) amyloidosis in Japanese patients and the treatment strategy for the condition. Methods We conducted a survey of Japanese AL amyloidosis patients, who were treated between January 1, 2012, and December 31, 2014. Results A total of 741 AL amyloidosis patients were included in this study (436 men and 305 women; median age: 65 years old, range: 31-93). The most frequently affected organ was the kidneys (n=542), followed by the heart (n=252), gastrointestinal (GI) tract (n=164), autonomic nervous system (n=131), liver (n=71), and peripheral nervous system (n=71). Diagnostic findings were most commonly detected in the GI tract (upper GI tract: 350 cases, lower GI tract: 167 cases), followed by the bone marrow and kidneys. An abdominal fat-pad biopsy was only conducted in 128 patients. Autologous stem cell transplants (ASCTs) and bortezomib were used to treat 126 and 276 patients, respectively. Conclusion The clinical features of Japanese patients with systemic AL amyloidosis are similar to those reported previously for cases in the US and Europe. Regarding treatment, a significant number of ASCTs were performed in Japan as well as in Western countries. Surprisingly, a marked number of patients received bortezomib as a treatment for AL amyloidosis.
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Affiliation(s)
- Chihiro Shimazaki
- Department of Hematology, Japan Community Health care Organization Kyoto Kuramaguchi Medical Center, Japan
| | - Hiroyuki Hata
- Department of Immunology and Hematology, Graduate School of Health Sciences, Kumamoto University, Japan
| | - Sinsuke Iida
- Department of Hematology and Oncology, Nagoya City University Graduate School of Medical Sciences, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Shuichi Ikeda
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Japan
| | - Masahide Yazaki
- Department of Biological Sciences for Intractable Neurological Diseases, Institute for Biomedical Sciences, Shinshu University, Japan
| | - Wakaba Fukushima
- Department of Public Health, Osaka City University Faculty of Medicine, Japan
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
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Milani P, Palladini G, Merlini G. New concepts in the treatment and diagnosis of amyloidosis. Expert Rev Hematol 2018; 11:117-127. [DOI: 10.1080/17474086.2018.1424534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
- PhD program in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation ‘Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo’, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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25
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Muchtar E, Dispenzieri A, Lacy MQ, Buadi FK, Kapoor P, Hayman SR, Gonsalves W, Warsame R, Kourelis TV, Chakraborty R, Russell S, Lust JA, Lin Y, Go RS, Zeldenrust S, Rajkumar SV, Dingli D, Leung N, Kyle RA, Kumar SK, Gertz MA. Overuse of organ biopsies in immunoglobulin light chain amyloidosis (AL): the consequence of failure of early recognition. Ann Med 2017; 49:545-551. [PMID: 28271734 DOI: 10.1080/07853890.2017.1304649] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION The diagnosis of amyloidosis requires histological confirmation of Congo-red (CR) deposits. The tissue source is preferably fat aspiration and/or bone marrow (BM) biopsy, but at times organ biopsy is required. METHODS We studied 612 patients with systemic immunoglobulin light chain amyloidosis to characterise the tissues used to establish the diagnosis. RESULTS The median number of tissue samples was 3. About 95% of BM biopsies were stained for CR, while 79% of patients had fat aspiration CR-stained. CR stain sensitivity was 69% in BM, 75% in fat aspiration and 89% for both sources combined. In comparison, CR sensitivity was 97-100% for heart, renal and liver biopsies. About 42% of patients with renal involvement, 21% of patients with liver involvement and 13% of patients with heart involvement underwent organ biopsy, when a less invasive biopsy would have established the diagnosis. Predictors for the requirement for organ biopsy were male sex, limited organ involvement and lack of fat aspiration. DISCUSSION Fat aspiration is underutilised for histologic confirmation of amyloidosis. A high rate of organ biopsies represents a failure to recognise the disease. Early awareness of amyloidosis in patients with organ dysfunction may lead to more judicious use of organ biopsies in this disease. Key messages Fat pad aspiration is underutilised to establish the diagnosis of amyloidosis. Bone marrow and fat pad aspiration obviates the need for invasive biopsies. The excessive use of organ biopsy in AL amyloidosis reflects failure to recognise the disease early in its course.
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Affiliation(s)
- Eli Muchtar
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | | | - Martha Q Lacy
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Francis K Buadi
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Prashant Kapoor
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | | | | | - Rahma Warsame
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | | | - Rajshekhar Chakraborty
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA.,b Internal Medicine Department , Essentia Health St. Joseph's Hospital , Brainerd , MN , USA
| | - Stephen Russell
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - John A Lust
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Yi Lin
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Ronald S Go
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | | | | | - David Dingli
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Nelson Leung
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA.,c Division of Nephrology and Hypertension , Mayo Clinic , Rochester , MN , USA
| | - Robert A Kyle
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Shaji K Kumar
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
| | - Morie A Gertz
- a Division of Haematology , Mayo Clinic , Rochester , MN , USA
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26
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Milani P, Basset M, Russo F, Foli A, Palladini G, Merlini G. The lung in amyloidosis. Eur Respir Rev 2017; 26:26/145/170046. [DOI: 10.1183/16000617.0046-2017] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 05/31/2017] [Indexed: 01/10/2023] Open
Abstract
Amyloidosis is a disorder caused by misfolding of autologous protein and its extracellular deposition as fibrils, resulting in vital organ dysfunction and eventually death. Pulmonary amyloidosis may be localised or part of systemic amyloidosis.Pulmonary interstitial amyloidosis is symptomatic only if the amyloid deposits severely affect gas exchange alveolar structure, thus resulting in serious respiratory impairment. Localised parenchymal involvement may be present as nodular amyloidosis or as amyloid deposits associated with localised lymphomas. Finally, tracheobronchial amyloidosis, which is usually not associated with evident clonal proliferation, may result in airway stenosis.Because the treatment options for amyloidosis are dependent on the fibril protein type, the workup of all new cases should include accurate determination of the amyloid protein. Most cases are asymptomatic and need only a careful follow-up. Diffuse alveolar-septal amyloidosis is treated according to the underlying systemic amyloidosis. Nodular pulmonary amyloidosis is usually localised, conservative excision is usually curative and the long-term prognosis is excellent. Tracheobronchial amyloidosis is usually treated with bronchoscopic interventions or external beam radiation therapy.
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Systemic Light Chain Amyloidosis Mimicking Rheumatic Disorders. Case Rep Med 2017; 2016:7649510. [PMID: 28042297 PMCID: PMC5153512 DOI: 10.1155/2016/7649510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/26/2016] [Accepted: 09/28/2016] [Indexed: 12/17/2022] Open
Abstract
Secondary amyloidosis can complicate chronic inflammatory autoimmune diseases. However, the clinical findings of primary amyloidosis may mimic those of primary rheumatologic disorders. We present the case of a 53-year-old woman who presented with dystrophic nail changes, dry eyes, bilateral carpal tunnel syndrome, Raynaud's phenomenon, and high titer positive nucleolar pattern antinuclear antibody. She was initially misdiagnosed as having Undifferentiated Connective Tissue Disease (UCTD). On further workup, she was eventually diagnosed with lambda light chain systemic amyloidosis by abdominal fat pad biopsy. Her symptoms completely resolved after autologous stem cell transplantation. With this case, we would like to highlight the similarities in the clinical features between light chain amyloidosis and rheumatological disorders. We would also like to emphasize the importance of the prompt recognition of the clinical features of amyloidosis which are crucial to triggering appropriate diagnostic procedures, since early diagnosis is a key to improving outcomes in this disease with an otherwise poor prognosis.
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Sethi N, Sedighi Manesh R, Sperling A, Bresler SC, Connell NT, Tierney LM. Factoring in the missing link. Am J Hematol 2017; 92:110-113. [PMID: 27486087 DOI: 10.1002/ajh.24501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 07/27/2016] [Accepted: 07/31/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Nilay Sethi
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | | | - Adam Sperling
- Department of Medical Oncology; Dana Farber Cancer Institute; Boston Massachusetts
| | - Scott C. Bresler
- Department of Pathology; Brigham and Women's Hospital; Boston Massachusetts
| | - Nathan T. Connell
- Hematology Division; Department of Medicine, Brigham and Women's Hospital; Boston Massachusetts
- Department of Medicine; Harvard Medical School; Boston Massachusetts
| | - Lawrence M. Tierney
- Medicine Department; University of California; San Francisco California
- Medicine Department; San Francisco Veterans Affair Medical Center; San Francisco California
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Abstract
Tissue deposition of protein fibrils causes a group of rare diseases called systemic amyloidoses. This Seminar focuses on changes in their epidemiology, the current approach to diagnosis, and advances in treatment. Systemic light chain (AL) amyloidosis is the most common of these conditions, but wild-type transthyretin cardiac amyloidosis (ATTRwt) is increasingly being diagnosed. Typing of amyloid fibrils, a critical determinant of therapy, has improved with the wide availability of laser capture and mass spectrometry from fixed histological tissue sections. Specific and accurate evaluation of cardiac amyloidosis is now possible using cardiac magnetic resonance imaging and cardiac repurposing of bone scintigraphy tracers. Survival in AL amyloidosis has improved markedly as novel chemotherapy agents have become available, but challenges remain in advanced disease. Early diagnosis, a key to better outcomes, still remains elusive. Broadening the amyloid-specific therapeutic landscape to include RNA inhibitors, fibril formation stabilisers and inhibitors, and immunotherapeutic targeting of amyloid deposits holds promise to transform outcomes in systemic amyloidoses.
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Affiliation(s)
- Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
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30
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Milani P, Merlini G. Monoclonal IgM-related AL amyloidosis. Best Pract Res Clin Haematol 2016; 29:241-248. [DOI: 10.1016/j.beha.2016.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/16/2016] [Indexed: 12/11/2022]
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31
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What is new in diagnosis and management of light chain amyloidosis? Blood 2016; 128:159-68. [PMID: 27053535 DOI: 10.1182/blood-2016-01-629790] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 04/05/2016] [Indexed: 12/21/2022] Open
Abstract
Light chain (AL) amyloidosis is caused by a usually small plasma cell clone producing a misfolded light chain that deposits in tissues. Survival is mostly determined by the severity of heart involvement. Recent studies are clarifying the mechanisms of cardiac damage, pointing to a toxic effect of amyloidogenic light chains and offering new potential therapeutic targets. The diagnosis requires adequate technology, available at referral centers, for amyloid typing. Late diagnosis results in approximately 30% of patients presenting with advanced, irreversible organ involvement and dying in a few months despite modern treatments. The availability of accurate biomarkers of clonal and organ disease is reshaping the approach to patients with AL amyloidosis. Screening of early organ damage based on biomarkers can help identify patients with monoclonal gammopathy of undetermined significance who are developing AL amyloidosis before they become symptomatic. Staging systems and response assessment based on biomarkers facilitate the design and conduction of clinical trials, guide the therapeutic strategy, and allow the timely identification of refractory patients to be switched to rescue therapy. Treatment should be risk-adapted. Recent studies are linking specific characteristics of the plasma cell clone to response to different types of treatment, moving toward patient-tailored therapy. In addition, novel anti-amyloid treatments are being developed that might be combined with anti-plasma cell chemotherapy.
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32
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Muchtar E, Buadi FK, Dispenzieri A, Gertz MA. Immunoglobulin Light-Chain Amyloidosis: From Basics to New Developments in Diagnosis, Prognosis and Therapy. Acta Haematol 2016; 135:172-90. [PMID: 26771835 DOI: 10.1159/000443200] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 11/19/2022]
Abstract
Immunoglobulin amyloid light-chain (AL) amyloidosis is the most common form of systemic amyloidosis, where the culprit amyloidogenic protein is immunoglobulin light chains produced by marrow clonal plasma cells. AL amyloidosis is an infrequent disease, and since presentation is variable and often nonspecific, diagnosis is often delayed. This results in cumulative organ damage and has a negative prognostic effect. AL amyloidosis can also be challenging on the diagnostic level, especially when demonstration of Congo red-positive tissue is not readily obtained. Since as many as 31 known amyloidogenic proteins have been identified to date, determination of the amyloid type is required. While several typing methods are available, mass spectrometry has become the gold standard for amyloid typing. Upon confirming the diagnosis of amyloidosis, a pursuit for organ involvement is essential, with a focus on heart involvement, even in the absence of suggestive symptoms for involvement, as this has both prognostic and treatment implications. Details regarding initial treatment options, including stem cell transplantation, are provided in this review. AL amyloidosis management requires a multidisciplinary approach with careful patient monitoring, as organ impairment has a major effect on morbidity and treatment tolerability until a response to treatment is achieved and recovery emerges.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minn., USA
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Abstract
Immunoglobulin light chain amyloidosis (AL) is a rare, complex disease caused by misfolded free light chains produced by a usually small, indolent plasma cell clone. Effective treatments exist that can alter the natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of AL amyloidosis are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. The suppression of the amyloidogenic light chains using the cardiac biomarkers as guide to choose chemotherapy is still the mainstay of therapy. There are exciting possibilities ahead, including the study of oral proteasome inhibitors, antibodies directed at plasma cell clone, and finally antibodies attacking the amyloid deposits are entering the clinic, offering unprecedented opportunities for radically improving the care of this disease.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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34
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Suzuki T, Kusumoto S, Yamashita T, Masuda A, Kinoshita S, Yoshida T, Takami-Mori F, Takino H, Ito A, Ri M, Ishida T, Komatsu H, Ueda M, Ando Y, Inagaki H, Iida S. Labial salivary gland biopsy for diagnosing immunoglobulin light chain amyloidosis: a retrospective analysis. Ann Hematol 2015; 95:279-85. [DOI: 10.1007/s00277-015-2549-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 11/05/2015] [Indexed: 12/30/2022]
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35
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Nowak JK, Grulkowski I, Karnowski K, Wojtkowski M, Walkowiak J. Optical Coherence Tomography of the Labial Salivary Glands Reveals Age-Related Differences in Women. Clin Transl Sci 2015; 8:717-21. [PMID: 26530049 DOI: 10.1111/cts.12344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The labial minor salivary glands (LSGs) play a role in medical research and practice due to their superficial location and involvement in both systemic and localized diseases. Swept-source optical coherence tomography (OCT) is a noninvasive modality that enables in vivo, micrometer resolution, wide-field three-dimensional imaging in seconds. A purpose-built swept-source OCT instrument was employed to acquire three-dimensional datasets covering the area of 2.43 cm(2) of the mucosa of the lower lip to the depth of 3.4 mm in young (n = 14; mean age ± SD: 27 ± 3 years; body mass index [BMI] 20.4 ± 2.3 kg/m(2) ) and middle-aged women (n = 11; 54 ± 6 years; 25.5 ± 3.2 kg/m(2) ). Glandular tissue reflectivity mode (range 0-255; 86 ± 17 vs. 68 ± 12, p = 0.005), average single LSG area in tissue sample (5.26 ± 2.62 mm(2) vs. 2.87 ± 1.26 mm(2) , p = 0.011), and LSG surface filling factor (0.23 ± 0.13 vs. 0.11 ± 0.10, p = 0.027) had higher values in younger than in middle-aged women. A correlation between BMI and glandular tissue reflectivity mode (Spearman's ρ = -0.60) was found (p = 0.002). The results highlight the potential value of LSGs' OCT morphometry in research regarding ageing.
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Affiliation(s)
- Jan Krzysztof Nowak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Ireneusz Grulkowski
- Faculty of Physics, Astronomy and Informatics, Institute of Physics, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Karol Karnowski
- Faculty of Physics, Astronomy and Informatics, Institute of Physics, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Maciej Wojtkowski
- Faculty of Physics, Astronomy and Informatics, Institute of Physics, Nicolaus Copernicus University in Torun, Torun, Poland
| | - Jaroslaw Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poznan, Poland
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Palladini G, Milani P, Merlini G. Novel strategies for the diagnosis and treatment of cardiac amyloidosis. Expert Rev Cardiovasc Ther 2015; 13:1195-211. [PMID: 26496239 DOI: 10.1586/14779072.2015.1093936] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous protein. The presence of heart involvement is the most important prognostic determinant. The diagnosis of amyloid cardiac involvement relies on echocardiography and magnetic resonance imaging, while scintigraphy with bone tracers is helpful in differentiating light chain amyloidosis from other types of amyloidosis involving the heart. Although these diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started before irreversible cardiac damage has occurred. Refined diagnostic techniques, accurate patients' stratification based on biomarkers of cardiac dysfunction, the availability of novel, more powerful drugs, and ultimately, the unveiling of the cellular mechanisms of cardiac damage created a favorable environment for a dramatic improvement in the treatment of this disease that we expect in the next few years.
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Affiliation(s)
- Giovanni Palladini
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- a Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
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37
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Kastritis E, Dimopoulos MA. Recent advances in the management of AL Amyloidosis. Br J Haematol 2015; 172:170-86. [DOI: 10.1111/bjh.13805] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics; National and Kapodistrian University of Athens; School of Medicine; Athens Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics; National and Kapodistrian University of Athens; School of Medicine; Athens Greece
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Lavatelli F, Albertini R, Di Fonzo A, Palladini G, Merlini G. Biochemical markers in early diagnosis and management of systemic amyloidoses. Clin Chem Lab Med 2015; 52:1517-31. [PMID: 24870609 DOI: 10.1515/cclm-2014-0235] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 02/03/2023]
Abstract
Systemic amyloid diseases are characterized by widespread protein deposition as amyloid fibrils. Precise diagnostic framing is the prerequisite for a correct management of patients. This complex process is achieved through a series of steps, which include detection of the tissue amyloid deposits, identification of the amyloid type, demonstration of the amyloidogenic precursor, and evaluation of organ dysfunction/damage. Laboratory medicine plays a central role in the diagnosis and management of systemic amyloidoses, through the quantification of the amyloidogenic precursor and evaluation of end-organ damage using biomarkers.
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39
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A practical approach to the diagnosis of systemic amyloidoses. Blood 2015; 125:2239-44. [PMID: 25636337 DOI: 10.1182/blood-2014-11-609883] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 01/25/2015] [Indexed: 12/13/2022] Open
Abstract
Accurate diagnosis of systemic amyloidosis is necessary both for assessing the prognosis and for delineating the appropriate treatment. It is based on histologic evidence of amyloid deposits and characterization of the amyloidogenic protein. We prospectively evaluated the diagnostic performance of immunoelectron microscopy (IEM) of abdominal fat aspirates from 745 consecutive patients with suspected systemic amyloidoses. All cases were extensively investigated with clinical and laboratory data, with a follow-up of at least 18 months. The 423 (56.8%) cases with confirmed systemic forms were used to estimate the diagnostic performance of IEM. Compared with Congo-red-based light microscopy, IEM was equally sensitive (75% to 80%) but significantly more specific (100% vs 80%; P < .001). In amyloid light-chain (AL) amyloidosis, κ cases were more difficult to diagnose (sensitivity 71%), whereas the analysis of abdominal aspirate was informative in only 40% of patients with transthyretin amyloidosis. We found a high prevalence (20%) of a monoclonal component in patients with non-AL amyloidosis, highlighting the risk of misdiagnosis and the need for unequivocal amyloid typing. Notably, IEM identified correctly the specific form of amyloidosis in >99% of the cases. IEM of abdominal fat aspirates is an effective tool in the routine diagnosis of systemic amyloidoses.
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Minimally invasive minor salivary gland biopsy for the diagnosis of amyloidosis in a rheumatology clinic. ISRN RHEUMATOLOGY 2014; 2014:354648. [PMID: 24707407 PMCID: PMC3953425 DOI: 10.1155/2014/354648] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 01/15/2014] [Indexed: 11/24/2022]
Abstract
Background. Systemic amyloidosis is a potentially fatal condition, unless diagnosed and treated before development of irreversible organ damage.
Demonstration of amyloid deposits within tissue biopsies is only definitive diagnostic method, which makes appropriate selection of biopsy site essential. Herein,
we evaluated efficacy of minimally invasive minor salivary gland biopsy (MSGB) for the diagnosis of amyloidosis. Methods. We analyzed 37 biopsies taken from
35 patients. Suggestive findings for amyloidosis were significant proteinuria, renal impairment, refractory diarrhea, neuropathy, and restrictive cardiomyopathy.
Minor salivary gland was the initial biopsy site in all subjects. When MSGB was negative but there was a high suspicion for amyloidosis, a kidney, duodenum,
or rectal biopsy was performed for further investigation. Results. Mean age of patients was 45.4 and 21 were female. In 11 patients amyloidosis was diagnosed
with MSGB. In overall 18 patients were diagnosed with amyloidosis. Sixteen of them were identified as being of AA type and two were AL type amyloidosis.
The sensitivity of minimally invasive MSGB is 61.1% for diagnosing amyloidosis in this study. Conclusion. MSGB is a safe and simple method for the diagnosis
of amyloidosis which can be performed in an outpatient setting. We suggest extensive use of this minimally invasive method.
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Merlini G, Comenzo RL, Seldin DC, Wechalekar A, Gertz MA. Immunoglobulin light chain amyloidosis. Expert Rev Hematol 2013; 7:143-56. [PMID: 24350907 DOI: 10.1586/17474086.2014.858594] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Primary light chain amyloidosis is the most common form of systemic amyloidosis and is caused by misfolded light chains that cause proteotoxicity and rapid decline of vital organ function. Early diagnosis is essential in order to deliver effective therapy and prevent irreversible organ damage. Accurate diagnosis requires clinical skills and advanced technologies. The disease can be halted and the function of target organs preserved by the prompt reduction and elimination of the plasma cell clone producing the toxic light chains in the bone marrow. Heart damage is the major determinant of survival, and staging with cardiac biomarkers guides treatment. Two-thirds of patients can benefit from treatment with improved quality of life and extended survival. Future efforts should be directed at early diagnosis, improving the tolerability and efficacy of anti-plasma cell therapy, accelerating recovery of organ function via promoting resorption of amyloid deposits, and developing novel approaches to counter light chain proteotoxicity.
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Affiliation(s)
- Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Foundation Scientific Institute San Matteo, Amyloidosis Research and Treatment Center, V.le Golgi 19 27100, Pavia, Italy
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Abstract
Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous proteins. Although these diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of systemic amyloidoses are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. Internists play a key role in suspecting the disease, thus allowing early diagnosis, starting the diagnostic workup and selecting patients that should be referred to specialized centers, judiciously titrating supportive measures, and following patients throughout the course of the disease. Here we review the pathogenesis, diagnosis and treatment of the most common forms of systemic amyloidoses.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Abstract
In immunoglobulin light chain amyloidosis a small, indolent plasma cell clone synthesizes light chains that cause devastating organ damage. Early diagnosis, based on prompt recognition of "red-flags" before advanced cardiomyopathy ensues, is essential for improving outcomes. Differentiation from other systemic amyloidoses may require advanced technologies. Prognosis depends on the extent of cardiac involvement, and cardiac biomarkers guide the choice of therapy. The protean clinical presentation requires individualized treatment. Close monitoring of clonal and organ response guides therapy changes and duration. Conventional or high-dose alkylator-based chemotherapy is effective in almost two-thirds of patients. Combinations of proteasome inhibitors, dexamethasone, and alkylators achieve high response rates, although controlled studies are needed. Risk-adapted stem cell transplant and consolidation with novel agents may be considered in selected patients. Immune-modulatory drugs are good options for refractory/relapsed patients. Novel agents and therapeutic targets are expected to be exploited, in an integrated, more effective and less toxic treatment strategy.
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