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Sidiqi MH, Aljama MA, Buadi FK, Warsame RM, Lacy MQ, Dispenzieri A, Dingli D, Gonsalves WI, Kumar S, Kapoor P, Kourelis T, Hogan WJ, Gertz MA. Stem Cell Transplantation for Light Chain Amyloidosis: Decreased Early Mortality Over Time. J Clin Oncol 2018; 36:1323-1329. [DOI: 10.1200/jco.2017.76.9554] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Autologous stem-cell transplantation (ASCT) has been used in patients with immunoglobulin light chain (AL) amyloidosis for more than two decades. Early experience raised concerns regarding safety with high early-mortality rates. Patients and Methods We report 20 years of experience with ASCT for AL amyloidosis at the Mayo Clinic Rochester. In all, 672 consecutive patients receiving ASCT for AL amyloidosis were divided into three cohorts on the basis of date of transplantation (cohort 1, 1996-2002 [n = 124]; cohort 2, 2003-2009 [n = 302]; and cohort 3, 2010-2016 [n = 246]). Results The median age for the entire cohort was 59 years, with patients in cohort 3 being slightly older than those in the other two cohorts (60 v 58 v 54 years for cohorts 3, 2, and 1, respectively; P < .001). Fewer patients in cohort 3 had more than two organs involved (9% v 18% v 19% for cohorts 3, 2, and 1, respectively; P < .001). More patients received pretransplantation therapy in cohort 3 compared with earlier time periods (49% v 38% v 42% for cohorts 3, 2, and 1, respectively; P = .02). Hematologic response was higher in cohort 3 (84% v 79% v 69% for cohorts 3, 2, and 1, respectively; P = .002). Median overall survival for the entire cohort was 122 months and improved over time (not reached v 120 months v 75 months for cohorts 3, 2, and 1, respectively; P < .001). Treatment-related mortality declined over time (2.4% v 8.6% v 14.5% for cohorts 3, 2, and 1, respectively; P < .001). On multivariable analysis, conditioning dose, Mayo stage 2012, and hematologic response were independent predictors of survival. Conclusion ASCT is a highly effective therapy for AL amyloidosis. The improved survival and markedly reduced treatment-related mortality in eligible patients indicate that this will remain an important first-line option even in the era of treatment approaches that use novel agents.
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Affiliation(s)
| | | | | | | | | | | | - David Dingli
- All authors: Mayo Clinic Rochester, Rochester, MN
| | | | - Shaji Kumar
- All authors: Mayo Clinic Rochester, Rochester, MN
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Abstract
Amyloid cardiomyopathy should be suspected in any patient who presents with heart failure and preserved ejection fraction. In patients with echocardiographic evidence of ventricular thickening and without a clear history of hypertension, infiltrative cardiomyopathy should be considered. If imaging suggests the presence of amyloid deposits, confirmation by biopsy is required, although endomyocardial biopsy is generally not necessary. Assessment of aspirated subcutaneous fat and bone-marrow biopsy samples verifies the diagnosis in 40-80% of patients, dependent on the type of amyloidosis. Mass spectroscopy can be used to determine the protein subunit and classify the disease as immunoglobulin light-chain amyloidosis or transthyretin-related amyloidosis associated with mutant or wild-type TTR (formerly known as familial amyloid cardiomyopathy and senile cardiac amyloidosis, respectively). In this Review, we discuss the characteristics of cardiac amyloidosis, and present a structured approach to both the assessment of patients and treatment with emerging therapies and organ transplantation.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Angela Dispenzieri
- Division of Clinical Biochemistry and Immunology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Taimur Sher
- Division of Hematology/Oncology, Cancer Center, and Breast Clinic, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Venner CP, Gillmore JD, Sachchithanantham S, Mahmood S, Lane T, Foard D, Roussel M, Rannigan L, Gibbs SD, Pinney JH, Whelan CJ, Lachmann HJ, Hawkins PN, Wechalekar AD. Stringent patient selection improves outcomes in systemic light-chain amyloidosis after autologous stem cell transplantation in the upfront and relapsed setting. Haematologica 2014; 99:e260-3. [PMID: 25193959 DOI: 10.3324/haematol.2014.108191] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Christopher P Venner
- National Amyloidosis Centre, University College London Medical School, UK Cross Cancer Institute, University of Alberta, Edmonton, Canada
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London Medical School, UK
| | | | - Shameem Mahmood
- National Amyloidosis Centre, University College London Medical School, UK
| | - Thirusha Lane
- National Amyloidosis Centre, University College London Medical School, UK
| | - Darren Foard
- National Amyloidosis Centre, University College London Medical School, UK
| | | | - Lisa Rannigan
- National Amyloidosis Centre, University College London Medical School, UK
| | - Simon Dj Gibbs
- National Amyloidosis Centre, University College London Medical School, UK Central Manchester University Hospital, Department of Clinical Haematology, Manchester, UK
| | - Jennifer H Pinney
- National Amyloidosis Centre, University College London Medical School, UK
| | - Carol J Whelan
- National Amyloidosis Centre, University College London Medical School, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London Medical School, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London Medical School, UK
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Auto-SCT improves survival in systemic light chain amyloidosis: a retrospective analysis with 14-year follow-up. Bone Marrow Transplant 2014; 49:1036-41. [PMID: 24887378 DOI: 10.1038/bmt.2014.115] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/13/2014] [Accepted: 03/14/2014] [Indexed: 02/03/2023]
Abstract
Optimal treatment approach continues to remain a challenge for systemic light chain amyloidosis (AL). So far, Auto-SCT is the only modality associated with long-term survival. However, failure to show survival benefit in randomized study raises questions regarding its efficacy. We present a comparative outcome analysis of Auto-SCT to conventional therapies (CTR) in AL patients treated over a 14-year period at our institution. Out of the 145 AL amyloidosis patients, Auto-SCT was performed in 80 patients with 1-year non-relapse mortality rate of 12.5%. Novel agents were used as part of induction therapy in 56% of transplant recipients vs 46% of CTR patients. Hematological and organ responses were seen in 74.6% and 39% in the Auto-SCT arm vs 53% and 12% in the CTR arm, respectively. The projected 5-year survival for Auto-SCT vs CTR was 63% vs 38%, respectively. Landmark analysis of patients alive at 1-year after diagnosis showed improved 5-year OS of 72% with Auto-SCT vs 65% in the CTR arm. In the multivariate analysis, age <60 years, induction therapy with novel agents, kidney only involvement and Auto-SCT were associated with improved survival. In conclusion, Auto-SCT is associated with long-term survival for patients with AL amyloidosis.
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