1
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Bellofatto IA, Schindler TH, Portincasa P, Carbone F, Canepa M, Liberale L, Montecucco F. Early diagnosis and management of cardiac amyloidosis: A clinical perspective. Eur J Clin Invest 2024; 54:e14160. [PMID: 38217112 DOI: 10.1111/eci.14160] [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: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024]
Abstract
Cardiac amyloidosis multidisciplinary team (MDT). We propose the creation of a multidisciplinary team (MDT) for cardiac amyloidosis in which internal medicine physicians could take a lead role in coordinating other specialists involved in patient care. Created with BioRender.com.
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Affiliation(s)
- Ilaria Anna Bellofatto
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, Cardiovascular Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Bari, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
| | - Marco Canepa
- Cardiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
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2
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Haran A, Vaxman I, Gatt ME, Lebel E. Immune Therapies in AL Amyloidosis-A Glimpse to the Future. Cancers (Basel) 2024; 16:1605. [PMID: 38672686 PMCID: PMC11048972 DOI: 10.3390/cancers16081605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Light-chain (AL) amyloidosis is a rare plasma cell disorder characterized by the deposition of misfolded immunoglobulin light chains in target organs, leading to multi-organ dysfunction. Treatment approaches have historically mirrored but lagged behind those of multiple myeloma (MM). Recent advancements in MM immunotherapy are gradually being evaluated and adopted in AL amyloidosis. This review explores the current state of immunotherapeutic strategies in AL amyloidosis, including monoclonal antibodies, antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T-cell therapy. We discuss the unique challenges and prospects of these therapies in AL amyloidosis, including the exposure of frail AL amyloidosis patients to immune-mediated toxicities such as cytokine release syndrome (CRS) and immune effector-cell-associated neurotoxicity syndrome (ICANS), as well as their efficacy in promoting rapid and deep hematologic responses. Furthermore, we highlight the need for international initiatives and compassionate programs to provide access to these promising therapies and address critical unmet needs in AL amyloidosis management. Finally, we discuss future directions, including optimizing treatment sequencing and mitigating toxicities, to improve outcomes for AL amyloidosis patients.
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Affiliation(s)
- Arnon Haran
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Iuliana Vaxman
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 49100, Israel;
| | - Moshe E. Gatt
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Eyal Lebel
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
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3
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Charliński G, Steinhardt M, Rasche L, Gonzalez-Calle V, Peña C, Parmar H, Wiśniewska-Piąty K, Dávila Valls J, Olszewska-Szopa M, Usnarska-Zubkiewicz L, Gozzetti A, Ciofini S, Gentile M, Zamagni E, Kurlapski M, Legieć W, Vesole DH, Jurczyszyn A. Outcomes of Modified Mayo Stage IIIa and IIIb Cardiac Light-Chain Amyloidosis: Real-World Experience in Clinical Characteristics and Treatment-67 Patients Multicenter Analysis. Cancers (Basel) 2024; 16:1592. [PMID: 38672674 PMCID: PMC11048847 DOI: 10.3390/cancers16081592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Light-chain amyloidosis (AL) is a rare multisystem disorder characterized by the deposition of misfolded amyloid fibrils derived from monoclonal immunoglobulin light chains in various organs. One of the most common organs involved in AL is the heart, with 50-70% of patients clinically symptomatic at diagnosis. We conducted a multi-center, retrospective analysis of 67 patients diagnosed between July 2012 and August 2022 with the European 2012 modification of Mayo 2004 stage III cardiac AL. The most important factors identified in the univariate Cox analysis contributing to a longer OS included Eastern Cooperative Oncology Group performance status (ECOG PS) ≤ 1, New York Heart Association functional classification (NYHA FC) ≤ 2, the use of autologous stem cell transplantation (ASCT) after induction treatment, achieving a hematological response (≥very good partial response) and cardiac (≥partial response) response after first-line treatment. The most important prognostic factors with the most significant impact on OS improvement in patients with modified Mayo stage III cardiac AL identified by multivariate Cox analysis are ECOG PS ≤ 1, NYHA FC ≤ 2, and achieving hematological response ≥ VGPR and cardiac response ≥ PR after first-line treatment.
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Affiliation(s)
- Grzegorz Charliński
- Department of Nephrology, Hypertension and Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
- Department of Hematology and Bone Marrow Transplantation, Nicolaus Copernicus Hospital, 87-100 Torun, Poland
| | - Maximilian Steinhardt
- Department of Internal Medicine II, University Hospital of Wurzburg, 97080 Wurzburg, Germany; (M.S.); (L.R.)
- Interdisciplinary Amyloidosis Center of Northern Bavaria, University Hospital Wurzburg, 97080 Wurzburg, Germany
| | - Leo Rasche
- Department of Internal Medicine II, University Hospital of Wurzburg, 97080 Wurzburg, Germany; (M.S.); (L.R.)
| | - Veronica Gonzalez-Calle
- a Servicio de Hematología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Centro de Investigación del Cáncer de Salamanca, 37007 Salamanca, Spain
| | - Camila Peña
- Department of Hematology, Hospital del Salvador, Santiago 7500922, Chile;
| | - Harsh Parmar
- Division of Multiple Myeloma, John Theurer Cancer Center at Hackensack, Meridian School of Medicine, Hackensack, NJ 07701, USA;
| | - Katarzyna Wiśniewska-Piąty
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, 40-055 Katowice, Poland;
| | - Julio Dávila Valls
- Servicio de Hematologia, Hospital Nuestra Señora de Sonsoles, 05004 Ávila, Spain;
| | - Magdalena Olszewska-Szopa
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, 51-141 Wroclaw, Poland; (M.O.-S.); (L.U.-Z.)
| | - Lidia Usnarska-Zubkiewicz
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, 51-141 Wroclaw, Poland; (M.O.-S.); (L.U.-Z.)
| | - Alessandro Gozzetti
- Hematology, Department of Medical Science, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (A.G.); (S.C.)
| | - Sara Ciofini
- Hematology, Department of Medical Science, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy; (A.G.); (S.C.)
| | - Massimo Gentile
- Hematology Unit, Department of Onco-Hematology, A.O. of Cosenza, 87100 Cosenza, Italy
- Department of Pharmacy, Health and Nutritional Science, University of Calabria, 87036 Rende, Italy;
| | - Elena Zamagni
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia ‘Seràgnoli’, Università di Bologna, 40126 Bologna, Italy;
| | - Michał Kurlapski
- Department of Hematology and Transplantology, Medical University of Gdańsk, 81-519 Gdańsk, Poland;
| | - Wojciech Legieć
- Department of Hematology and Bone Marrow Transplantation, St. John of Dukla Oncology Center of Lublin Land, 20-090 Lublin, Poland;
| | - David H. Vesole
- Division of Multiple Myeloma, John Theurer Cancer Center at Hackensack, Meridian School of Medicine, Hackensack, NJ 07701, USA;
- Division of Hematology/Oncology, Medstar Georgetown University Hospital, Washington, DC 20007, USA;
| | - Artur Jurczyszyn
- Plasma Cell Dyscrasias Center, Department of Hematology, Faculty of Medicine, Jagiellonian University College of Medicine, 31-066 Kraków, Poland;
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4
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Kastritis E, Misra A, Gurskyte L, Kroi F, Verhoek A, Vermeulen J, Ammann E, Lam A, Cote S, Wechalekar AD. Assessing the prognostic utility of hematologic response for overall survival in patients with newly diagnosed AL amyloidosis: results of a meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2157581. [PMID: 36607151 DOI: 10.1080/16078454.2022.2157581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Amyloid light-chain (AL) amyloidosis is a rare disease characterized by amyloid fibril deposits made up of toxic light chains causing progressive organ dysfunction and death. Recent studies suggest that hematologic response may be an important prognostic indicator of overall survival (OS) in AL amyloidosis. The aim of this study was to evaluate the trial-level association between hematologic complete response (CR) or very good partial response or better (≥ VGPR) and OS in newly diagnosed patients. METHODS Studies were identified via systematic literature review. Pooled effect estimates were generated by a random-effects model. RESULTS Nine observational studies reporting hematologic CR or ≥VGPR and OS hazard ratios (HRs) were included in the meta-analysis. Achieving hematologic CR was associated with improved OS (HR, 0.21; 95% confidence interval [CI] 0.13-0.34). Achieving ≥ VGPR was also associated with improved OS (HR 0.21; 95% CI 0.17-0.26). Results of a sensitivity analysis excluding one outlier study revealed no heterogeneity and a better overall HR estimate. Potential limitations of this meta-analysis include the small number of eligible studies (consistent with the rarity of the disease) and inconsistencies in reporting of results. CONCLUSIONS Overall, our findings support the use of deep hematologic response (CR or ≥VGPR) as a clinical trial endpoint in newly diagnosed AL amyloidosis. This study provides evidence that early hematologic response is a strong patient-level surrogate for long-term OS in patients with AL amyloidosis receiving frontline therapy. Structured data collection of depth of response in future trials will further strengthen these observations.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | - Eric Ammann
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Annette Lam
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Sarah Cote
- Janssen Global Services, LLC, Raritan, NJ, USA
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5
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Machine Learning Approaches in Diagnosis, Prognosis and Treatment Selection of Cardiac Amyloidosis. Int J Mol Sci 2023; 24:ijms24065680. [PMID: 36982754 PMCID: PMC10051237 DOI: 10.3390/ijms24065680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
Cardiac amyloidosis is an uncommon restrictive cardiomyopathy featuring an unregulated amyloid protein deposition that impairs organic function. Early cardiac amyloidosis diagnosis is generally delayed by indistinguishable clinical findings of more frequent hypertrophic diseases. Furthermore, amyloidosis is divided into various groups, according to a generally accepted taxonomy, based on the proteins that make up the amyloid deposits; a careful differentiation between the various forms of amyloidosis is necessary to undertake an adequate therapeutic treatment. Thus, cardiac amyloidosis is thought to be underdiagnosed, which delays necessary therapeutic procedures, diminishing quality of life and impairing clinical prognosis. The diagnostic work-up for cardiac amyloidosis begins with the identification of clinical features, electrocardiographic and imaging findings suggestive or compatible with cardiac amyloidosis, and often requires the histological demonstration of amyloid deposition. One approach to overcome the difficulty of an early diagnosis is the use of automated diagnostic algorithms. Machine learning enables the automatic extraction of salient information from “raw data” without the need for pre-processing methods based on the a priori knowledge of the human operator. This review attempts to assess the various diagnostic approaches and artificial intelligence computational techniques in the detection of cardiac amyloidosis.
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6
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Wechalekar AD, Fontana M, Quarta CC, Liedtke M. AL Amyloidosis for Cardiologists: Awareness, Diagnosis, and Future Prospects: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:427-441. [PMID: 36444232 PMCID: PMC9700258 DOI: 10.1016/j.jaccao.2022.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare, debilitating, often fatal disease. Symptoms of cardiomyopathy are common presenting features, and patients often are referred to cardiologists. Cardiac amyloid infiltration is the leading predictor of death. However, the variable presentation and perceived rarity of the disease frequently lead to delay in suspecting amyloidosis as a cause of heart failure, leading to misdiagnoses and a marked delay in diagnosis, with devastating consequences for the patient. A median time from symptom onset to correct diagnosis of about 2 years is often too long when median survival from diagnosis for patients with AL amyloidosis and cardiomyopathy is 4 months to 2 years. The authors highlight the challenges to diagnosis, identify gaps in the current knowledge, and summarize novel treatments on the horizon to raise awareness about the critical need for early recognition of symptoms and diagnosis of AL amyloidosis aimed at accelerating treatment and improving outcomes for patients.
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Key Words
- AL amyloidosis
- AL, amyloid light chain
- ASCT, autologous stem cell transplantation
- ATTR, transthyretin
- CMR, cardiac magnetic resonance imaging
- CR, complete response
- CyBorD, cyclophosphamide-bortezomib-dexamethasone
- FLC, free light chain
- Ig, immunoglobulin
- LGE, late gadolinium enhancement
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- PCD, plasma cell dyscrasia
- QoL, quality of life
- VGPR, very good partial response
- awareness
- diagnosis
- future therapies
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Affiliation(s)
| | - Marianna Fontana
- National Amyloidosis Centre, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - C. Cristina Quarta
- Alexion Pharmaceuticals, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Michaela Liedtke
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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Fedotov SA, Khrabrova MS, Anpilova AO, Dobronravov VA, Rubel AA. Noninvasive Diagnostics of Renal Amyloidosis: Current State and Perspectives. Int J Mol Sci 2022; 23:ijms232012662. [PMID: 36293523 PMCID: PMC9604123 DOI: 10.3390/ijms232012662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022] Open
Abstract
Amyloidoses is a group of diseases characterized by the accumulation of abnormal proteins (called amyloids) in different organs and tissues. For systemic amyloidoses, the disease is related to increased levels and/or abnormal synthesis of certain proteins in the organism due to pathological processes, e.g., monoclonal gammopathy and chronic inflammation in rheumatic arthritis. Treatment of amyloidoses is focused on reducing amyloidogenic protein production and inhibition of its aggregation. Therapeutic approaches critically depend on the type of amyloidosis, which underlines the importance of early differential diagnostics. In fact, the most accurate diagnostics of amyloidosis and its type requires analysis of a biopsy specimen from the disease-affected organ. However, absence of specific symptoms of amyloidosis and the invasive nature of biomaterial sampling causes the late diagnostics of these diseases, which leads to a delayed treatment, and significantly reduces its efficacy and patient survival. The establishment of noninvasive diagnostic methods and discovery of specific amyloidosis markers are essential for disease detection and identification of its type at earlier stages, which enables timely and targeted treatment. This review focuses on current approaches to the diagnostics of amyloidoses, primarily with renal involvement, and research perspectives in order to design new specific tests for early diagnosis.
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Affiliation(s)
- Sergei A. Fedotov
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg 199034, Russia
| | - Maria S. Khrabrova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | - Anastasia O. Anpilova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | | | - Aleksandr A. Rubel
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Department of Genetics and Biotechnology, St. Petersburg State University, St. Petersburg 199034, Russia
- Correspondence: ; Tel.: +7-812-428-40-09
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8
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Puckrin R, Lee H, Tay J, Duggan P, McCulloch S, Neri P, Bahlis N, Jimenez-Zepeda VH. Suboptimal response for AL amyloidosis: is it time for early switch? Experience from a single amyloid program. Amyloid 2022; 29:208-209. [PMID: 35341414 DOI: 10.1080/13506129.2022.2055459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Robert Puckrin
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Holly Lee
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Jason Tay
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada.,Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Peter Duggan
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada.,Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Sylvia McCulloch
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Paola Neri
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada.,Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Nizar Bahlis
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada.,Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Victor H Jimenez-Zepeda
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada.,Charbonneau Cancer Research Institute, Calgary, AB, Canada
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9
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Ravichandran S, Law S, Mahmood S, Wisniowski B, Foard D, Fontana M, Martinez-Naharro A, Whelan C, Gillmore JD, Lachmann HJ, Hawkins PN, Wechalekar AD. Early relapse is an adverse prognostic marker in systemic immunoglobulin light chain (AL) Amyloidosis. Leukemia 2022; 36:1180-1184. [PMID: 34987193 PMCID: PMC8979816 DOI: 10.1038/s41375-021-01497-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/02/2021] [Accepted: 12/09/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Sriram Ravichandran
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Steven Law
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Brenden Wisniowski
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Darren Foard
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Carol Whelan
- 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
| | - Helen J Lachmann
- 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
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.
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10
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Hur JY, Yoon SE, Kim D, Choi JO, Min JH, Kim BJ, Kim JS, Lee JE, Choi JY, Jeon ES, Kim SJ, Kim K. Outcomes of bortezomib combination chemotherapies in autologous stem cell transplantation-ineligible patients with AL amyloidosis. Blood Res 2021; 56:266-278. [PMID: 34801989 PMCID: PMC8721454 DOI: 10.5045/br.2021.2021121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/01/2021] [Accepted: 10/06/2021] [Indexed: 11/17/2022] Open
Abstract
Background Treatment protocols for light chain (AL) amyloidosis have been derived from myeloma treatment. Bortezomib is a key drug used for the treatment of myeloma and AL amyloidosis. We retrospectively investigated the efficacy and toxicity of bortezomib- based chemotherapy in patients with newly diagnosed AL amyloidosis. Methods We reviewed the outcomes of newly diagnosed autologous stem cell transplantation (auto-SCT)-ineligible AL amyloidosis patients who received bortezomib-based chemotherapy at a referral center between 2011 and 2017. Results Of 63 patients who received bortezomib-based chemotherapy, 32 were male, and the median age was 66 years (range, 42‒82 yr). The hematologic overall response rate (ORR) was 65.1%, and the chemotherapy regimen with the best hematologic response was VMP (75.7%, 28/37). Sixty patients had significant organ (heart or kidney) involvement; 28.3% of patients (N=17) had major organ responses after chemotherapy. With a median follow- up of 34 months, there was no significant difference in progression-free survival (P=0.49) or overall survival (P =0.67) according to regimen. Most hematologic and non-hematologic problems were manageable. Conclusion Various chemotherapy combinations based on bortezomib are currently employed in the clinical setting, but no difference was found in terms of efficacy or toxicity.
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Affiliation(s)
- Joon Young Hur
- Division of Hematology and Oncology, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sang Eun Yoon
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Darae Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ju-Hong Min
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Jun Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Sun Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Eun Lee
- Division of Nephrology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seok Jin Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kihyun Kim
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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11
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Staron A, Zheng L, Doros G, Connors LH, Mendelson LM, Joshi T, Sanchorawala V. Marked progress in AL amyloidosis survival: a 40-year longitudinal natural history study. Blood Cancer J 2021; 11:139. [PMID: 34349108 PMCID: PMC8338947 DOI: 10.1038/s41408-021-00529-w] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 12/15/2022] Open
Abstract
The recent decades have ushered in considerable advancements in the diagnosis and treatment of systemic light chain (AL) amyloidosis. As disease outcomes improve, AL amyloidosis-unrelated factors may impact mortality. In this study, we evaluated survival trends and primary causes of death among 2337 individuals with AL amyloidosis referred to the Boston University Amyloidosis Center. Outcomes were analyzed according to date of diagnosis: 1980-1989 (era 1), 1990-1999 (era 2), 2000-2009 (era 3), and 2010-2019 (era 4). Overall survival increased steadily with median values of 1.4, 2.6, 3.3, and 4.6 years for eras 1–4, respectively (P < 0.001). Six-month mortality decreased over time from 23% to 13%. Wide gaps in survival persisted amid patient subgroups; those with age at diagnosis ≥70 years had marginal improvements over time. Most deaths were attributable to disease-related factors, with cardiac failure (32%) and sudden unexpected death (23%) being the leading causes. AL amyloidosis-unrelated mortality increased across eras (from 3% to 16% of deaths) and with longer-term survival (29% of deaths occurring >10 years after diagnosis). Under changing standards of care, survival improved and early mortality declined over the last 40 years. These findings support a more optimistic outlook for patients with AL amyloidosis.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Luke Zheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa M Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA. .,Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.
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12
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Wang L, Swerdel JN, Weaver J, Weiss B, Pan G, Yuan Z, DiBattiste PM. Incidence rate of hospitalization and mortality in the first year following initial diagnosis of cardiac amyloidosis in the US claims databases. Curr Med Res Opin 2021; 37:1275-1281. [PMID: 33830834 DOI: 10.1080/03007995.2021.1913109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to determine rates of hospitalization and in-hospital mortality in the first year following amyloidosis diagnosis with cardiac involvement using observational databases. METHODS Three administrative claims databases, IBM MarketScan® Commercial Claims and Encounters (CCAE), IBM MarketScan® Multi-State Medicare Database (MDCR), and Optum's de-identified Clinformatics® Data Mart Database (Optum) were analyzed. Adults ≥18 years old, with a diagnosis of amyloidosis and evidence of cardiac involvement (i.e. heart failure, heart block, or cardiomyopathy) but no hepatic/renal failure prior to amyloidosis diagnosis were included for analysis. The primary analyses identified patients between 01-01-2010 and 31-12-2017 period. We calculated the rates of hospitalization and in-hospital mortality within 1 year after the initial diagnosis of amyloidosis. A sensitivity analysis was conducted for patients identified in Optum database during 2004-2011 period, which provided additional mortality information. RESULTS A total of 419, 654, and 922 patients from CCAE, MDCR, and Optum were identified during 2010-2017 period, with mean age of 55.6, 77.8, and 74.2 years, respectively. Within 1 year following initial amyloidosis diagnosis, incidence rates (95% confidence interval [CI]) of hospitalization were 78.4 (66.3, 90.4), 78.6 (69.2, 87.9), and 61.2 (54.4, 68.0) per 100 person-years, rates of in-hospital mortality were 16.5 (11.8, 21.3), 8.4 (5.7, 11.0), and 17.7 (14.5, 21.0) per 100 person-years, in CCAE, MDCR, and Optum, respectively. The mortality rate from the sensitivity analysis among patients identified in Optum 2004-2011 period was higher compared with Optum 2010-2017 period. CONCLUSIONS The results from this study indicate that amyloidosis with cardiac involvement is a condition with high rates of hospitalization and mortality in the first year after initial diagnosis. Future studies are needed to further evaluate the outcomes within the subtypes of amyloidosis and understand the risk factors associated with poor prognoses.
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Affiliation(s)
- Lu Wang
- Janssen Research & Development LLC, Titusville, NJ, USA
| | | | - James Weaver
- Janssen Research & Development LLC, Titusville, NJ, USA
| | - Brendan Weiss
- Janssen Research & Development LLC, Spring House, PA, USA
| | - Guohua Pan
- Janssen Research & Development LLC, Spring House, PA, USA
| | - Zhong Yuan
- Janssen Research & Development LLC, Titusville, NJ, USA
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13
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Scalloped Tongue in Primary Amyloidosis. J Gen Intern Med 2021; 36:2456-2457. [PMID: 34027604 PMCID: PMC8342718 DOI: 10.1007/s11606-021-06890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
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14
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Adam RD, Coriu D, Jercan A, Bădeliţă S, Popescu BA, Damy T, Jurcuţ R. Progress and challenges in the treatment of cardiac amyloidosis: a review of the literature. ESC Heart Fail 2021; 8:2380-2396. [PMID: 34089308 PMCID: PMC8318516 DOI: 10.1002/ehf2.13443] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/04/2021] [Accepted: 05/12/2021] [Indexed: 12/19/2022] Open
Abstract
Cardiac amyloidosis is a restrictive cardiomyopathy determined by the accumulation of amyloid, which is represented by misfolded protein fragments in the cardiac extracellular space. The main classification of systemic amyloidosis is determined by the amyloid precursor proteins causing a very heterogeneous disease spectrum, but the main types of amyloidosis involving the heart are light chain (AL) and transthyretin amyloidosis (ATTR). AL, in which the amyloid precursor is represented by misfolded immunoglobulin light chains, can involve almost any system carrying the worst prognosis among amyloidosis patients. This has however dramatically improved in the last few years with the increased usage of the novel therapies such as proteasome inhibitors and haematopoietic cell transplantation, in the case of timely diagnosis and initiation of treatment. The treatment for AL is directed by the haematologist working closely with the cardiologist when there is a significant cardiac involvement. Transthyretin (TTR) is a protein that is produced by the liver and is involved in the transportation of thyroid hormones, especially thyroxine and retinol binding protein. ATTR results from the accumulation of transthyretin amyloid in the extracellular space of different organs and systems, especially the heart and the nervous system. Specific therapies for ATTR act at various levels of TTR, from synthesis to deposition: TTR tetramer stabilization, oligomer aggregation inhibition, genetic therapy, amyloid fibre degradation, antiserum amyloid P antibodies, and antiserum TTR antibodies. Treatment of systemic amyloidosis has dramatically evolved over the last few years in both AL and ATTR, improving disease prognosis. Moreover, recent studies revealed that timely treatment can lead to an improvement in clinical status and in a regression of amyloid myocardial infiltration showed by imaging, especially by cardiac magnetic resonance, in both AL and ATTR. However, treating cardiac amyloidosis is a complex task due to the frequent association between systemic congestion and low blood pressure, thrombo-embolic and haemorrhagic risk balance, patient frailty, and generally poor prognosis. The aim of this review is to describe the current state of knowledge regarding cardiac amyloidosis therapy in this constantly evolving field, classified as treatment of the cardiac complications of amyloidosis (heart failure, rhythm and conduction disturbances, and thrombo-embolic risk) and the disease-modifying therapy.
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Affiliation(s)
- Robert Daniel Adam
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Daniel Coriu
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Andreea Jercan
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Sorina Bădeliţă
- Department of HematologyFundeni Clinical InstituteBucharestRomania
| | - Bogdan A. Popescu
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
| | - Thibaud Damy
- French Referral Center for Cardiac AmyloidosisAmyloidosis Mondor NetworkCréteilFrance
- Department of CardiologyHenri Mondor Hospital/AP‐HPCréteilFrance
| | - Ruxandra Jurcuţ
- Department of CardiologyEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’3rd Cardiology Department, 258 Fundeni StreetBucharest022328Romania
- University of Medicine and Pharmacy ‘Carol Davila’BucharestRomania
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15
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Hassan H, Anwer F, Javaid A, Hashmi H. Progress in research: Daratumumab improves treatment outcomes of patients with AL amyloidosis. Crit Rev Oncol Hematol 2021; 165:103435. [PMID: 34343658 DOI: 10.1016/j.critrevonc.2021.103435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 07/13/2021] [Accepted: 07/28/2021] [Indexed: 12/19/2022] Open
Abstract
Outcomes for patients with systemic light-chain (AL) amyloidosis have improved over the last two decades with timely diagnosis, use of novel chemotherapeutic agents, risk stratification and better patient selection criteria before hematopoietic autologous stem cell transplant (ASCT). However, majority of patients have advanced stage disease at initial presentation and at relapse rendering them ineligible for intensive cytotoxic chemotherapy or ASCT. Daratumumab (Dara) with or without standard chemotherapy appears to be an excellent treatment option for newly diagnosed and relapsed refractory AL amyloidosis. This is largely due to its tolerable safety and remarkable efficacy as seen in multiple retrospective, small phase II studies as well as a phase III randomized controlled trial. Here we review published clinical trials and retrospective data of Dara in AL amyloidosis that explore its role as a valuable addition to the treatment armamentarium for this challenging disease.
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Affiliation(s)
- Hamza Hassan
- Department of Hematology & Medical Oncology, Boston University School of Medicine, United States.
| | - Faiz Anwer
- Department of Hematology and Medical Oncology, Taussig Cancer Center, Cleveland Clinic, United States
| | - Anum Javaid
- Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Hamza Hashmi
- Department of Hematology Oncology, Medical University of South Carolina, United States
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16
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D'Souza A, Myers J, Cusatis R, Dispenzieri A, Finkel M, Panepinto J, Flynn KE. Development of a conceptual model of patient-reported outcomes in light chain amyloidosis: a qualitative study. Qual Life Res 2021; 31:1083-1092. [PMID: 34255276 DOI: 10.1007/s11136-021-02943-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Light chain (AL) amyloidosis is a plasma cell neoplasm associated with high early mortality and severe morbidity that can cause severe disability. We explored the impact of AL amyloidosis on symptoms and well-being from the perspectives of patients and health care providers who regularly care for AL patients. We intended to develop a conceptual understanding of patient-reported outcomes in AL amyloidosis to identify the context of use and concept of interest for a clinical outcome assessments tool in this disease. METHOD Twenty patients and ten professionals were interviewed. Patient interviews captured the spectrum of amyloidosis experience including time from diagnosis, type of organ involvement, and presence and type of treatment received. Interviews with professionals included physicians, advanced practice providers, registered nurse, and a patient advocate; these interviews covered similar topics. RESULTS The impact of AL amyloidosis on patients' life was multidimensional, with highly subjective perceptions of normality and meaning. Four major themes from patients and experts included diagnosis of AL amyloidosis, living with AL amyloidosis, symptom burden, and social roles. Barriers to patient-reported outcomes data collection in patients were additionally explored from experts. The themes provide a comprehensive understanding of the important experiences of symptom burden and its impact on daily life from AL amyloidosis patients' and from the perspectives of professionals who care for patients with AL amyloidosis. CONCLUSION These findings further the conceptual understanding and identification of a preliminary model of concept of interest for development of a clinical outcome assessments tool for AL amyloidosis.
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Affiliation(s)
- Anita D'Souza
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
| | - Judith Myers
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Rachel Cusatis
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Angela Dispenzieri
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Muriel Finkel
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Julie Panepinto
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Kathryn E Flynn
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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17
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Gorini F, Coi A, Mezzasalma L, Baldacci S, Pierini A, Santoro M. Survival of patients with rare diseases: a population-based study in Tuscany (Italy). Orphanet J Rare Dis 2021; 16:275. [PMID: 34127030 PMCID: PMC8201697 DOI: 10.1186/s13023-021-01907-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Rare diseases (RDs) encompass a heterogeneous group of life-threatening or chronically debilitating conditions that individually affect a small number of subjects but overall represent a major public health issue globally. There are still limited data on RD burden due to the paucity of large population-based epidemiological studies. The aim of this research was to provide survival estimates of patients with a RD residing in Tuscany, Italy. Methods Cases collected in the Rare Diseases Registry of Tuscany with diagnosis between 1st January 2000 and 31th December 2018 were linked to the regional health databases in order to retrieve information on mortality of all subjects. Survival at 1, 5 and 10 years from diagnosis with 95% confidence intervals (CI) was estimated by sex, age class, nosological group and subgroup using the Kaplan–Meier method. The effect of sex, age and period of diagnosis (years 2000–2009 or 2010–2018) on survival was estimated using Cox proportional hazards regression. Results Survival at 1, 5 and 10 years from diagnosis was 97.3%, 88.8% and 80.8%, respectively. Respiratory diseases and peripheral and central nervous system disorders were characterized by the lowest survival at 5 and 10 years. Despite a modest higher prevalence of RDs among females (54.0% of the total), male cases had a significant increased risk of death (hazard ratio, HR 1.48, 95% CI 1.38–1.58). Cases diagnosed during 2010–2018 period had a risk of death significantly lower than those diagnosed during 2000–2009 (HR 0.81, 95% CI 0.82–0.96), especially for immune system disorders (HR 0.48, 95% CI 0.26–0.87), circulatory system diseases (HR 0.61, 95% CI 0.45–0.84) and diseases of the musculoskeletal system and connective tissue (HR 0.64, 95% CI 0.49–0.84). Conclusions An earlier diagnosis as well as the improvement in the efficacy of treatment resulted in a decreased risk of death over the years for specific RDs. The linkage between a population-based registry and other regional databases exploited in this study provides a large and accurate mass of data capable of estimating patients’ life-expectancy and increasing knowledge on the collective burden of RDs. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-021-01907-0.
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Affiliation(s)
- Francesca Gorini
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy.
| | - Alessio Coi
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy
| | - Lorena Mezzasalma
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy
| | - Silvia Baldacci
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy
| | - Anna Pierini
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy.,Fondazione Toscana "Gabriele Monasterio", Pisa, Italy
| | - Michele Santoro
- Unit of Epidemiology of Rare Diseases and Congenital Anomalies, Institute of Clinical Physiology, National Research Council, via Moruzzi 1, 56124, Pisa, Italy
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Abstract
Opportunities and challenges in the field of systemic amyloidosis can be grouped into 4 categories. First, a deeper understanding of the pathogenesis of the disease is required. Second, a greater awareness of the disease, which will lead to an earlier diagnosis, is imperative. Third, end points for interventional trials are required to convey us to our fourth aspirations, which are novel therapies for patients with light chain amyloidosis.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, 200 First Street SW Rochester, MN 55905, USA.
| | - Giampaolo Merlini
- Amyloidosis Center, Foundation IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, Pavia 27100, Italy
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19
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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20
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Prognostic restaging after treatment initiation in patients with AL amyloidosis. Blood Adv 2021; 5:1029-1036. [PMID: 33595624 DOI: 10.1182/bloodadvances.2020003782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 11/20/2022] Open
Abstract
The utility of systemic light chain (AL) amyloidosis staging systems has been validated for newly diagnosed patients, but their role in restaging after treatment has not been explored. We designed this study to evaluate whether the currently used systems are of prognostic value at 3 and 6 months of starting first-line treatment, and whether stage migration from diagnosis impacts survival. This is a retrospective study including Mayo Clinic patients with AL amyloidosis diagnosed between 1 January 2006 and 30 June 2019; 536 and 204 patients had restaging data for at least 1 system at 3 and 6 months, respectively. Using modified Mayo 2004 staging at 3 months, median overall survival (OSs) were 11.8, 10.8, 4.6, and 1.1 years for stage I, II, IIIa, and IIIb, respectively. Using Mayo 2012, median OSs were 11.8, 9.0, 5.2, and 0.8 years for stage I, II, III, and IV, respectively. Using modified Mayo 2004 staging at 6 months, median OSs were not reached (NR), NR, 5.4, and 0.9 years for stage I, II, IIIa, and IIIb, respectively. Using Mayo 2012, OSs were NR, NR, 4.6, and 0.9 years for stage I, II, III, and IV, respectively. Worsening stage at 3 or 6 months was associated with worse survival than retaining baseline stage. In conclusion, the current staging systems can be used for restaging at 3 and 6 months from treatment initiation. Migration to higher stage predicts poor prognosis.
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21
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D'Souza A, Brazauskas R, Dispenzieri A, Panepinto J, Flynn KE. Changes in patient-reported outcomes in light chain amyloidosis in the first year after diagnosis and relationship to NT-proBNP change. Blood Cancer J 2021; 11:29. [PMID: 33563897 PMCID: PMC7873213 DOI: 10.1038/s41408-021-00412-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/15/2020] [Accepted: 10/23/2020] [Indexed: 12/28/2022] Open
Abstract
We conducted a prospective cohort study in newly diagnosed systemic light chain (AL) amyloidosis patients (N = 59) to study patient-reported outcomes (PROs) through the first year. The median age was 68 years with 42% female, 8% Black, and 78% lambda subtype. Organ involvement was cardiac in 66%, renal in 58%, with 25% having 3 or greater organs involved. Between baseline and 3 months, all PROMIS®-29 domain scores worsened by 0.4–4.1 points except anxiety which improved by 2.1 points. By 1 year, scores improved compared to the greatest decline at 3 months, most statistically significant for global physical health, physical function, and fatigue. On stage-adjusted survival analysis, in addition to baseline global physical and mental health, domains measuring physical function, fatigue, anxiety, depression, and social roles were associated with 1-year survival. At 1 year, PROMIS measures were associated with NT-proBNP changes and hematologic response. Among patients with an NT-proBNP response, the improvement was seen in physical function, social roles, global mental health, and anxiety. Among patients with an NT-proBNP progression, worsening was seen with anxiety, depression, sleep, and global mental health. Measuring and tracking PROs in patients with AL amyloidosis is important and these important outcomes can be used as correlative endpoints in clinical care/research.
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Affiliation(s)
- Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA.
| | - Ruta Brazauskas
- Division of Biostatistics, Institute of Health and Safety, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Julie Panepinto
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Kathryn E Flynn
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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22
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Abstract
PURPOSE OF REVIEW This article provides a summary of the autonomic neuropathies, including neuropathies associated with diabetes mellitus, neuropathies due to amyloid deposition, immune-mediated autonomic neuropathies (including those associated with a paraneoplastic syndrome), inherited autonomic neuropathies, and toxic autonomic neuropathies. The presenting features, diagnostic investigations, and natural history of these neuropathies are discussed. RECENT FINDINGS Recent findings in autonomic peripheral neuropathy include data on the epidemiology and atypical presentations of diabetic autonomic neuropathy, treatment-induced neuropathy of diabetes mellitus, the presentation of immune-mediated neuropathies, and advances in hereditary neuropathy associated with amyloidosis and other hereditary neuropathies. SUMMARY Knowledge and recognition of the clinical features of the autonomic neuropathies, combined with appropriate laboratory and electrophysiologic testing, will facilitate accurate diagnosis and management.
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23
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Abstract
Cardiac amyloidosis (CA) is an infiltrative and restrictive cardiomyopathy that leads to heart failure, reduced quality of life, and death. The disease has two main subtypes, transthyretin cardiac amyloidosis (ATTR-CA) and immunoglobulin light chain cardiac amyloidosis (AL-CA), characterized by the nature of the infiltrating protein. ATTR-CA is further subdivided into wild-type (ATTRwt-CA) and variant (ATTRv-CA) based on the presence or absence of a mutation in the transthyretin gene. CA is significantly underdiagnosed and increasingly recognized as a cause of heart failure with preserved ejection fraction. Advances in diagnosis that employ nuclear scintigraphy to diagnose ATTR-CA without a biopsy and the emergence of effective treatments, including transthyretin stabilizers and silencers, have changed the landscape of this field and render early and accurate diagnosis critical. This review summarizes the epidemiology, pathophysiology, diagnosis, prognosis, and management of CA with an emphasis on the significance of recent developments and suggested future directions.
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Affiliation(s)
- Jonah Rubin
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Irving Medical Center, Allen Hospital of NewYork-Presbyterian Hospital, New York, NY 10032, USA; ,
| | - Mathew S Maurer
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Irving Medical Center, Allen Hospital of NewYork-Presbyterian Hospital, New York, NY 10032, USA; ,
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24
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Schulman A, Connors LH, Weinberg J, Mendelson LM, Joshi T, Shelton AC, Sanchorawala V. Patient outcomes in light chain (AL) amyloidosis: The clock is ticking from symptoms to diagnosis. Eur J Haematol 2020; 105:495-501. [DOI: 10.1111/ejh.13472] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Amanda Schulman
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Lawreen H Connors
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Janice Weinberg
- Department of Biostatistics Boston University School of Public Health Boston Massachusetts USA
| | - Lisa M Mendelson
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Tracy Joshi
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Anthony C Shelton
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
| | - Vaishali Sanchorawala
- Amyloidosis Center Boston Medical Center Boston University School of Medicine Boston Massachusetts USA
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Jain A, Ramasamy K. Time to Redefine Risk-Stratification and Response Criteria in Immunoglobulin Light Chain Amyloidosis? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e769-e776. [PMID: 32653456 DOI: 10.1016/j.clml.2020.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/21/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis results from clonal plasma cell (PC)-derived immunoglobulin light chain-mediated end-organ dysfunction, the extent and severity of which predicts survival. Anti-PC therapies reduce clonal light chain burden, which usually results in improvement of organ function, and consequently overall survival. Response assessment is critical to gauge therapeutic efficacy, to report clinical trial outcomes, and to switch therapy in those without response. Response in AL amyloidosis is 2-fold: hematologic response and organ response (OR). Depth of hematologic response is graded on the basis of serum free light chain (sFLC) parameters, but assessment of OR is binary. The role of normal sFLC ratio or complete remission as a treatment end point has been challenged, thus highlighting the need to quantify involved FLC and residual PC beyond the normal sFLC ratio to possibly account for the ongoing organ damage seen in some patients with complete remission. Mass spectrometry and urinary exosome represent ultrasensitive strategies to estimate involved FLC below the detection threshold of current sFLC assays. The role of new sFLC parameters and minimal residual disease as potential prognostic parameters has been recognized. Brain natriuretic peptide (BNP) and 24-hour proteinuria:estimated glomerular filtration rate ratio were identified to overcome certain limitations of N-terminal-Pro-BNP, 24-hour proteinuria, and estimated glomerular filtration rate for cardiac and renal response assessment, respectively. Use of monoclonal antibodies targeting PC and amyloid deposits has expanded the therapeutic armamentarium of AL amyloidosis, and given their excellent efficacy, early ORs are reported. This review provides insights into recent advances in the risk-stratification and response assessment of patients with AL amyloidosis in light of the changing therapeutic paradigms. Incorporation of these advancements into formal consensus guidelines would require further validation.
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Affiliation(s)
- Ankur Jain
- Department of hematology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India.
| | - Karthik Ramasamy
- Department of Haematology, Oxford University Hospitals, NHS Foundation Trust; NIHR BRC Blood Theme, Oxford, England, UK; Oxford Myeloma Centre for Translational Research
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26
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Gertz MA. Immunoglobulin light chain amyloidosis: 2020 update on diagnosis, prognosis, and treatment. Am J Hematol 2020; 95:848-860. [PMID: 32267020 DOI: 10.1002/ajh.25819] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 01/10/2023]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or monoclonal gammopathy undetermined significance (MGUS)." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain (FLC) values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mmHg, troponin T < 0.06 ng/mL and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered cyclophosphamide-bortezomib-dexamethasone or daratumumab-containing regimens as it appears to be highly active in AL amyloidosis. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure.
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Affiliation(s)
- Morie A. Gertz
- Division of HematologyMayo Clinic Rochester Minnesota USA
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Varga C, Dorbala S, Lousada I, Polydefkis MJ, Wechalekar A, Maurer MS, Comenzo RL. The diagnostic challenges of cardiac amyloidosis: A practical approach to the two main types. Blood Rev 2020; 45:100720. [PMID: 32616304 DOI: 10.1016/j.blre.2020.100720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/28/2022]
Abstract
Systemic amyloidosis of the immunoglobulin light-chain (AL) or transthyretin type (ATTR) is a multisystem protein deposition disease that often involves the heart. Delays in diagnosis are very common and can have detrimental consequences on patient outcomes. Because both major types can now be distinguished quickly and treated effectively, clear approaches are required. There have been advances in radioisotope scintigraphy, monoclonal protein testing and mass spectrometry for typing that need coordinated application. We have entered an era in which rapid diagnosis and ready therapy will save lives, therefore we must develop coherent approaches to this multisystem disease. The prognosis for AL has improved significantly with the incorporation of novel agents such as proteasome inhibitors, immunomodulators and monoclonal antibodies against plasma cells. Multiple independent studies have demonstrated the efficacy of these agents in AL, though tolerability can become an issue with dose reductions required in many cases. Median overall survival for patients achieving complete responses after stem cell transplant and consolidation exceeds a decade. The prognosis for ATTR, both age-related wild-type (ATTRwt) and hereditary due to variants of transthyretin (ATTRv), has improved as well due to the availability of the stabilizer tafamidis and the RNA-interference agents patisiran and inotersen. In both AL and ATTR, with elimination or suppression of the pathologic amyloid-forming protein, symptomatic involvement of the heart, kidneys and peripheral nervous system can improve as well. In this review, we present the current state of diagnosing and treating the two major types of systemic amyloidosis, emphasizing the coherent clinical application of the new tools and treatments. Implementation of the approaches we provide will enable rapid identification of amyloid type and rational selection of therapy.
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Affiliation(s)
- Cindy Varga
- Department of Medicine, The John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Sharmila Dorbala
- Department of Radiology, Nuclear Medicine Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Michael J Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Mathew S Maurer
- Columbia University Irving Medical Center, New York, NY, USA
| | - Raymond L Comenzo
- Department of Medicine, The John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
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D’Souza A, Magnus BE, Myers J, Dispenzieri A, Flynn KE. The use of PROMIS patient-reported outcomes (PROs) to inform light chain (AL) amyloid disease severity at diagnosis. Amyloid 2020; 27:111-118. [PMID: 31971467 PMCID: PMC7275879 DOI: 10.1080/13506129.2020.1713743] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/18/2019] [Accepted: 01/07/2020] [Indexed: 12/19/2022]
Abstract
We sought to evaluate how PROMIS patient-reported outcome (PRO) measures correlated with disease characteristics in systemic light chain (AL) amyloidosis patients at diagnosis. Newly diagnosed AL patients were recruited at two centres (N = 61). Patients completed the PROMIS Global Health v1.2, PROMIS-29 Profile v2.0 and Fatigue 8a v1.0. We assigned disease severity based on stage, presence of cardiac AL, and number of organs involved. We evaluated a) known groups validity by comparing PROMIS T-scores by disease severity, b) internal consistency using Cronbach's alpha and c) convergent/discriminant validity based on correlations across the domains and summary scores. Using receiver operating characteristic (ROC) curve analysis, NT-proBNP cut-off level corresponding to normal/mild vs moderate/severe PRO scores was determined. The median age was 68 (48-83) years with 58% males. Sixty-six percent had cardiac involvement and 25% had 3 or more organs involved with AL amyloidosis; 14% had stage 1, 28% stage 2, 36% stage 3 and 16% stage 4 disease. PROMIS measures had acceptable to excellent internal consistency and expected patterns of correlations. PROMIS Global Physical Health score was worse than the Global Mental Health Score at diagnosis; Physical function, fatigue and anxiety were the most impaired domains. PROMIS Global Health summary scores discriminated across AL amyloidosis stage and number of organs involved. Physical Function showed the strongest effects across known groups by stage, cardiac involvement and number of organs involved followed by Ability to Participate in Social Roles and Activities. A diagnostic NT-proBNP cut-off of 4200 pg/ml identified patients with moderate/severe PRO scores for these domains. Our results provide evidence for reliability and validity of select PROMIS short form measures in AL amyloidosis at diagnosis.
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Affiliation(s)
- Anita D’Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Center for International Blood and Marrow Transplant Research
| | | | - Judith Myers
- Center for International Blood and Marrow Transplant Research
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kathryn E Flynn
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Center for International Blood and Marrow Transplant Research
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D'Souza A, Szabo A, Flynn KE, Dhakal B, Chhabra S, Pasquini MC, Weihrauch D, Hari PN. Adjuvant doxycycline to enhance anti-amyloid effects: Results from the dual phase 2 trial. EClinicalMedicine 2020; 23:100361. [PMID: 32529175 PMCID: PMC7280748 DOI: 10.1016/j.eclinm.2020.100361] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Although, doxycycline use is associated with improved outcomes in amyloidosis in retrospective studies, evidence from clinical trials is limited. METHODS This phase 2 trial of doxycycline (clinicaltrials.gov: NCT02207556) in newly diagnosed light chain (AL) amyloidosis enrolled 25 patients with systemic AL amyloidosis on treatment with doxycycline for 1 year along with chemotherapy. Outcomes of interest included mortality, organ response, and hematologic response rates at 1 year. FINDINGS The median age was 62 years, 64% were male, and 68% had the AL lambda subtype. Patients had Mayo 2012 stage 3 in 24% and stage 4 in 28%. Cardiac involvement was present in 60% of patients, renal involvement in 72%, and 60% patients had 3 or more organs involved. Target organ was cardiac in 14(56%), renal in 7(28%), hepatic in 1(4%) and soft tissue in 3(12%). At 1 year, mortality was 20% (95% confidence interval, 8.9-41.6%) and organ response was 36% (18-57%). Hematologic response in 1-year survivors was 100%, including 30% complete and 55% very good partial response. Autologous hematopoietic cell transplant was performed in 60%; among transplanted patients, day-100 transplant-related mortality was 0. Doxycycline use was safe and not attributed to any grade 2 or higher toxicity. INTERPRETATION In addition to a low 1-year mortality, doxycycline use was safe and associated with high transplant utilization rate. We thus contend that doxycycline should be studied in a placebo-controlled study in newly diagnosed AL patients in the first year, particularly among patients with advanced disease and cardiac involvement.
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Affiliation(s)
- Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, United States
- Corresponding author.
| | - Aniko Szabo
- Division of Biostatistics, Institute of Health and Safety, United States
| | - Kathryn E. Flynn
- Division of Hematology/Oncology, Department of Medicine, United States
| | - Binod Dhakal
- Division of Hematology/Oncology, Department of Medicine, United States
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Department of Medicine, United States
| | | | - Dorothee Weihrauch
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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30
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Comparison of different techniques to identify cardiac involvement in immunoglobulin light chain (AL) amyloidosis. Blood Adv 2020; 3:1226-1229. [PMID: 30975646 DOI: 10.1182/bloodadvances.2019032458] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/07/2019] [Indexed: 01/11/2023] Open
Abstract
We retrospectively reviewed the utility of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and transthoracic echocardiogram (TTE) in diagnosing cardiac involvement in patients with biopsy-proven systemic immunoglobulin light chain amyloidosis seen at the Mayo Clinic between 1 January 2006 and 30 December 2015. We analyzed 2 cohorts: patients undergoing endomyocardial biopsy for suspicion of cardiac involvement (cohort 1) and patients who had serum NT-proBNP and comprehensive echocardiographic evaluation at diagnosis (cohort 2). Of 179 patients undergoing endomyocardial biopsy (cohort 1), 173 (97%) had evidence of amyloid deposition, with 159 having NT-proBNP performed at the time of the procedure. The NT-proBNP was elevated (>300 pg/mL) in all 159 patients (sensitivity, 100%; median NT-proBNP, 4917 pg/mL; range, 355-69 541). The left ventricular ejection fraction, interventricular septal thickness, and strain rate were abnormal in 89/168 (53%), 102/64 (61%) and 92/95 (97%), respectively. Among cohort 2 (n = 342), 259 (76%) had an elevated NT-proBNP, of whom 237 (92%) had an abnormality detected on TTE. Of 83 patients with normal NT-proBNP <300 pg/mL, 27 (33%) had an abnormality on TTE (all with borderline strain rate -18% to -15%). Only 5/27 patients were considered to have possible early cardiac involvement and none had any other diagnostic or classical features of amyloidosis on TTE. The combination of NT-proBNP and comprehensive echocardiographic evaluation can diagnose cardiac amyloidosis negating the need for endomyocardial biopsy. A negative NT-proBNP rules out clinically meaningful cardiac involvement and may obviate the routine use of TTE in patients with a low clinical suspicion of cardiac amyloidosis.
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31
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Cohen OC, Sharpley F, Gillmore JD, Lachmann HJ, Sachchithanantham S, Mahmood S, Fontana M, Whelan CJ, Martinez-Naharro A, Kyriakou C, Rabin N, Popat R, Yong K, Cheesman S, Shah R, Hawkins PN, Wechalekar AD. Use of ixazomib, lenalidomide and dexamethasone in patients with relapsed amyloid light-chain amyloidosis. Br J Haematol 2020; 189:643-649. [PMID: 31984481 DOI: 10.1111/bjh.16401] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
With improving outcomes in amyloid light-chain (AL) amyloidosis, there is a need to study novel agents in this setting. We report outcomes of 40 patients with relapsed AL amyloidosis treated with ixazomib + lenalidomide + dexamethasone (IRd). Haematological responses were assessed on an intention-to-treat basis at three months: complete response (CR) - 8 (20·5%), very good partial response (VGPR) - 8 (20·5%), partial response (PR) - 7 (17·9%) and no response (NR) - 16 (41·0%). One patient had missing data. Six patients subsequently improved response. Best responses were: CR - 10 (25·6%), VGPR - 8 (20·5%), PR - 7 (17·9%), NR - 14 (35·9%). Cardiac and renal organ responses occurred in 5·6% and 13·3% respectively. Median progession-free survival (PFS) was 17·0 months (95% CI 7·3-20·7 months), improving to 28·8 months (95% CI 20·6-37·0 months) in those achieving CR/VGPR. Median overall survival was 29·1 months (95% CI 24-33 months). Serious adverse events were seen in 14 (35·0%) patients inclusive of 15 admissions due to: infection (6/15, 40·0%), fluid overload (5/15, 33·3%), cardiac arrhythmia (2/15, 13·3%), renal dysfunction (1/15, 6·6%) and anaemia (1/15, 6·6%). In summary, IRd is an oral treatment option with a manageable toxicity profile leading to deep responses in 47% of patients with relapsed AL amyloidosis.
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Affiliation(s)
- Oliver C Cohen
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Faye Sharpley
- 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
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Sajitha Sachchithanantham
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | | | - Neil Rabin
- University College London Hospitals NHS Trust, London, UK
| | - Rakesh Popat
- University College London Hospitals NHS Trust, London, UK
| | - Kwee Yong
- University College London Hospitals NHS Trust, London, UK
| | - Simon Cheesman
- University College London Hospitals NHS Trust, London, UK
| | - Raakhee Shah
- University College London Hospitals NHS Trust, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.,University College London Hospitals NHS Trust, London, UK
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Van de Wyngaert Z, Carpentier B, Pascal L, Lionne‐Huyghe P, Leduc I, Srour M, Vasseur M, Demarquette H, Terriou L, Herbaux C, Manier S, Bossard J, Barbieux S, Chauvet P, Willaume A, Nudel M, Bories C, Gibier J, Facon T, Boyle EM. Daratumumab is effective in the relapsed or refractory systemic light‐chain amyloidosis but associated with high infection burden in a frail real‐life population. Br J Haematol 2019; 188:e24-e27. [DOI: 10.1111/bjh.16282] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Zoe Van de Wyngaert
- Service des Maladies du Sang CHU Lille Lille France
- Hématologie et Thérapie Cellulaire Hôpital Saint Antoine APHP Université Sorbonne INSERM UMRs 938 Paris France
| | | | - Laurent Pascal
- Service d’Hématologie Hôpital Saint‐Vincent GHICL Lille France
| | | | - Isabelle Leduc
- Service de Médecine Interne CH Abbeville Abbeville France
| | - Micha Srour
- Service d’Hématologie CH Dunkerque Dunkerque France
| | | | | | | | | | | | | | | | - Paul Chauvet
- Service des Maladies du Sang CHU Lille Lille France
| | | | | | - Claire Bories
- Service des Maladies du Sang CHU Lille Lille France
- Service d’Hématologie CH Lens Lens France
| | - Jean‐Baptiste Gibier
- Service d’Anatomo‐pathologie Centre de Biologie Pathologie CHU Lille Lille France
| | | | - Eileen M. Boyle
- Service des Maladies du Sang CHU Lille Lille France
- Perlmutter Cancer Center NYU Langone Health New York NY USA
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33
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Sharpley FA, Fontana M, Martinez-Naharro A, Manwani R, Mahmood S, Sachchithanantham S, Lachmann HJ, Gillmore JD, Whelan CJ, Hawkins PN, Wechalekar AD. Cardiac biomarkers are prognostic in systemic light chain amyloidosis with no cardiac involvement by standard criteria. Haematologica 2019; 105:1405-1413. [PMID: 31399529 PMCID: PMC7193493 DOI: 10.3324/haematol.2019.217695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
Patients with systemic immunoglobulin light chain amyloidosis (AL) with no evidence of cardiac involvement by consensus criteria have excellent survival, but 20% will die within 5 years of diagnosis and prognostic factors remain poorly characterised. We report the outcomes of 378 prospectively followed Mayo stage I patients (N-terminal pro b-type natriuretic peptide <332 ng/L, high sensitivity cardiac troponin <55 ng/L). The median presenting N-terminal pro b-type natriuretic peptide was 161 ng/L, high sensitivity cardiac troponin 10 ng/L, creatinine 76 μmol/L and mean left ventricular septal wall thickness, 10 mm. Median follow up was 42 (1-117 months), with 71 deaths; median overall survival was not reached (78% survival at 5 years). Although no patients had cardiac involvement by echocardiogram, a proportion (n=25/90, 28%) had cardiac involvement by cardiac magnetic resonance imaging. Age, autonomic nervous system involvement, N-terminal pro b-type natriuretic peptide >152 ng/L, high sensitivity cardiac troponin >10 ng/L and cardiac involvement by magnetic resonance imaging were predictive for survival; on multivariate analysis only N-terminal pro b-type natriuretic peptide >152 ng/L (P<0.008, hazard ratio [HR] 3.180, confidence interval [CI]: 1.349-7.495) and cardiac involvement on magnetic resonance imaging (P=0.026, HR=5.360, CI: 1.219-23.574) were prognostic. At 5 years, 70% of patients with N-terminal pro b-type natriuretic peptide >152 ng/L were alive. In conclusion, N-terminal pro b-type natriuretic peptide is prognostic for survival in patients with no cardiac involvement by consensus criteria and cardiac involvement is detected by magnetic resonance imaging in such cases. This suggests that N-terminal pro b-type natriuretic peptide thresholds for cardiac involvement in AL may need to be redefined.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
| | | | - Richa Manwani
- National Amyloidosis Centre, University College London, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK
| | | | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | | | - Carol J Whelan
- National Amyloidosis Centre, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
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Wisniowski B, McLeod DSA, Adams R, Harvey Y, Brown I, McGuire L, Armes J, Mollee P. The epidemiology of amyloidosis in Queensland, Australia. Br J Haematol 2019; 186:829-836. [PMID: 31148162 DOI: 10.1111/bjh.16000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/11/2019] [Indexed: 11/30/2022]
Abstract
Published studies on the epidemiology of amyloidosis have relied on death certificate data for case ascertainment. We estimated the incidence and mortality burden of amyloidosis among residents of the Australian state, Queensland, aged ≥20 years for the years 1999-2013 based on case ascertainment from histopathology reports. Information systems for participating laboratories were scrutinised to identify histopathology reports that documented a diagnosis of amyloidosis. Case mortality status was determined via linkage to the National Death Index. A total of 447 cases of amyloidosis were identified, with a median age at diagnosis of 66 years. A plasma cell dyscrasia was identified in 72% of patients who had paraprotein studies performed. The estimated incidence for Queenslanders aged ≥20 years was 12·1 cases per million person years. The median survival was 2·45 years. Age at diagnosis, presence of a paraprotein, earlier year of diagnosis, and inner regional location of residence (compared with residence in a major city) were independently associated with reduced survival. Our data confirms previously reported incidence data for amyloidosis of approximately 10 cases per million patient years and indicates that survival for Queensland patients with amyloidosis is improving, though it remains poor for the elderly and patients with AL amyloidosis.
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Affiliation(s)
- Brendan Wisniowski
- Pathology Queensland, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
| | - Donald S A McLeod
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - Rebecca Adams
- Pathology Queensland, Woolloongabba, Queensland, Australia.,QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia.,QML Pathology, Mansfield, Queensland, Australia
| | - Yasmin Harvey
- Sullivan Nicolaides Pathology, Bowen Hills, Queensland, Australia
| | - Ian Brown
- Envoi Pathology, Kelvin Grove, Queensland, Australia
| | | | - Jane Armes
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Peter Mollee
- Pathology Queensland, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
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35
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Venkatesh SK, Hoodeshenas S, Venkatesh SH, Dispenzieri A, Gertz MA, Torbenson MS, Ehman RL. Magnetic Resonance Elastography of Liver in Light Chain Amyloidosis. J Clin Med 2019; 8:jcm8050739. [PMID: 31126105 PMCID: PMC6572504 DOI: 10.3390/jcm8050739] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/07/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
In this paper, we present our preliminary findings regarding magnetic resonance elastography (MRE) on the livers of 10 patients with systemic amyloidosis. Mean liver stiffness measurements (LSM) and spleen stiffness measurements (SSM) were obtained. Magnetic resonance imaging (MRI) images were analyzed for the distribution pattern of amyloid deposition. Pearson correlation analysis was performed in order to study the correlation between LSM, SSM, liver span, liver volume, spleen span, spleen volume, serum alkaline phosphatase (ALP), N-terminal pro b-type natriuretic peptide (NT pro BNP), and the kappa and lambda free light chains. An increase in mean LSM was seen in all patients. Pearson correlation analysis showed a statistically significant correlation between LSM and liver volume (r = 0.78, p = 0.007) and kappa chain level (r = 0.65, p = 0.04). Interestingly, LSM did not correlate significantly with SSM (r = 0.45, p = 0.18), liver span (r = 0.57, p = 0.08), or serum ALP (r = 0.60, p = 0.07). However, LSM correlated significantly with serum ALP when corrected for liver volume (partial correlation, r = 0.71, p = 0.03) and NT pro BNP levels (partial correlation, r = 0.68, p = 0.04). MRI review revealed that amyloid deposition in the liver can be diffuse, lobar, or focal. MRE is useful for the evaluation of hepatic amyloidosis and shows increased stiffness in hepatic amyloidosis. MRE has the potential to be a non-invasive quantitative imaging marker for hepatic amyloidosis.
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Affiliation(s)
- Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Safa Hoodeshenas
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Sandeep H Venkatesh
- Department of Radiology, Sengkang General Hospital, 110 Sengkang East Way, Singapore 544886, Singapore.
| | - Angela Dispenzieri
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Morie A Gertz
- Department of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Michael S Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Richard L Ehman
- Department of Radiology, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Ehman EC, El-Sady MS, Kijewski MF, Khor YM, Jacob S, Ruberg FL, Sanchorawala V, Landau H, Yee AJ, Bianchi G, Di Carli MF, Falk RH, Hyun H, Dorbala S. Early Detection of Multiorgan Light-Chain Amyloidosis by Whole-Body 18F-Florbetapir PET/CT. J Nucl Med 2019; 60:1234-1239. [PMID: 30954943 DOI: 10.2967/jnumed.118.221770] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 01/30/2019] [Indexed: 12/14/2022] Open
Abstract
Immunoglobulin light-chain (AL) amyloidosis affects multiple systemic organs. However, determination of the precise extent of organ involvement remains challenging. Targeted amyloid imaging with 18F-florbetapir PET/CT offers the potential to detect AL deposits in multiple organs. The primary aim of this study was to determine the distribution and frequency of AL deposits in the various organs of subjects with systemic AL amyloidosis using 18F-florbetapir PET/CT. Methods: This prospective study included 40 subjects with biopsy-proven AL amyloidosis including active AL amyloidosis (n = 30) or AL amyloidosis in hematologic remission for more than 1 y (n = 10). All subjects underwent 18F-florbetapir PET/CT, skull base to below the kidney scan field, from 60 to 90 min after injection of radiotracer. Volume-of-interest measurements of SUVmax were obtained using Hermes software for the parotid gland, tongue, thyroid, lung, gastric wall, pancreas, spleen, kidney, muscle, abdominal fat, lower thoracic spine, vertebral body, and humeral head. Uptake in each organ was visually compared with that in spine bone marrow. An SUVmax of at least 2.5 was considered abnormal in all organs other than the liver. Results: Compared with the international consensus definition of organ involvement, 18F-florbetapir PET/CT identified amyloid deposits in substantially higher percentages of subjects for several organ systems, including parotid gland (50% vs. 3%), tongue (53% vs. 10%), and lung (35% vs. 10%). In several organ systems, including kidney (13% vs. 28%) and abdominal wall fat (10% vs. 13%), PET identified involvement in fewer subjects than did international consensus. Quantitative analysis of 18F-florbetapir PET/CT revealed more frequent organ involvement than did visual analysis in the tongue, thyroid, lung, pancreas, kidney, muscle, and humeral head. Extensive organ amyloid deposits were observed in active AL as well as in AL remission cohorts, and in both cardiac and noncardiac AL cohorts. Conclusion: 18F-florbetapir PET/CT detected widespread organ amyloid deposition in subjects with both active AL and AL hematologic remission. In most instances, amyloid deposits in the various organs were not associated with clinical symptoms and, thus, were unrecognized. Early recognition of systemic organ involvement may help tailor treatment, and noninvasive monitoring of organ-level disease may guide management with novel fibril-resorbing therapies.
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Affiliation(s)
- Eric C Ehman
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - M Samir El-Sady
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marie F Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yiu Ming Khor
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sophia Jacob
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts
| | | | - Heather Landau
- Division of Medical Oncology, Memorial Sloan Kettering Medical Center, New York, New York
| | - Andrew J Yee
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Giada Bianchi
- Division of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Marcelo F Di Carli
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.,CV Imaging Program, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hyewon Hyun
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sharmila Dorbala
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts .,CV Imaging Program, Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts; and.,Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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He L, Anderson LC, Barnidge DR, Murray DL, Dasari S, Dispenzieri A, Hendrickson CL, Marshall AG. Classification of Plasma Cell Disorders by 21 Tesla Fourier Transform Ion Cyclotron Resonance Top-Down and Middle-Down MS/MS Analysis of Monoclonal Immunoglobulin Light Chains in Human Serum. Anal Chem 2019; 91:3263-3269. [DOI: 10.1021/acs.analchem.8b03294] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Lidong He
- Department of Chemistry and Biochemistry, Florida State University, Tallahassee, Florida 32310, United States
| | - Lissa C. Anderson
- National High Magnetic Field Laboratory, Florida State University, 1800 East Paul Dirac Dr., Tallahassee, Florida 32310, United States
| | | | | | | | | | - Christopher L. Hendrickson
- Department of Chemistry and Biochemistry, Florida State University, Tallahassee, Florida 32310, United States
- National High Magnetic Field Laboratory, Florida State University, 1800 East Paul Dirac Dr., Tallahassee, Florida 32310, United States
| | - Alan G. Marshall
- Department of Chemistry and Biochemistry, Florida State University, Tallahassee, Florida 32310, United States
- National High Magnetic Field Laboratory, Florida State University, 1800 East Paul Dirac Dr., Tallahassee, Florida 32310, United States
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Feng J, Zhang C, Shen K, Sun J, Fang Q, Zhang L, Cao X, Zhou D, Li J, Tian Z. Outcome of Cardiac Light-Chain Amyloidosis in the Era of Novel Therapy - A Single-Center Cohort Study of 227 Patients. Circ J 2019; 83:775-782. [PMID: 30773521 DOI: 10.1253/circj.cj-18-1048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiac involvement occurs in more than half of the patients with light-chain amyloidosis (AL), but the characteristics, treatment and prognosis of cardiac AL (CAL) are not fully described. Methods and Results: A total of 227 patients with CAL diagnosis between January 2009 and March 2017 at Peking Union Medical College Hospital were included. Patients with Mayo stages I, II and III AL accounted for 0.9%, 49.8% and 49.3%, respectively. Autologous stem cell transplantation, bortezomib combinations, non-bortezomib regimens and palliative treatment were given as first line therapy in 3.1%, 44.1%, 30.8% and 22.0% of patients, respectively. Overall hematological response and cardiac response were achieved in 60.6% and 37.2% of evaluable patients, respectively. The median overall survival (OS) was 17 months in all patients, and 10 months in those with Mayo stage III. In patients with Mayo stage III disease who survived for >1 month, the bortezomib group survived significantly longer than the non-bortezomib group (median OS, not reached vs. 12 months, P=0.019). Three independent prognostic factors for survival were identified: N-terminal fragment of B-type natriuretic peptide (NT-proBNP) ≥5,000 pg/mL, bone marrow plasma cells ≥10%, and systolic blood pressure <100 mmHg. CONCLUSIONS CAL patients had poor prognosis, but those treated with bortezomib combinations had a better outcome than the non-bortezomib group.
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Affiliation(s)
- Jun Feng
- Department of Hematology, Peking Union Medical College Hospital
| | - Congli Zhang
- Department of Hematology, Peking Union Medical College Hospital
| | - Kaini Shen
- Department of Hematology, Peking Union Medical College Hospital
| | - Jian Sun
- Department of Pathology, Peking Union Medical College Hospital
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital
| | - Xinxin Cao
- Department of Hematology, Peking Union Medical College Hospital
| | - Daobin Zhou
- Department of Hematology, Peking Union Medical College Hospital
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital
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Tang CX, Petersen SE, Sanghvi MM, Lu GM, Zhang LJ. Cardiovascular magnetic resonance imaging for amyloidosis: The state-of-the-art. Trends Cardiovasc Med 2019; 29:83-94. [DOI: 10.1016/j.tcm.2018.06.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 06/20/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023]
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40
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Binder C, Duca F, Stelzer PD, Nitsche C, Rettl R, Aschauer S, Kammerlander AA, Binder T, Agis H, Kain R, Hengstenberg C, Mascherbauer J, Bonderman D. Mechanisms of heart failure in transthyretin vs. light chain amyloidosis. Eur Heart J Cardiovasc Imaging 2019; 20:512-524. [DOI: 10.1093/ehjci/jey225] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Philipp Dominik Stelzer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Stefan Aschauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Andreas A Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Thomas Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Hermine Agis
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
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Eckhert E, Witteles R, Kaufman G, Lafayette R, Arai S, Schrier S, O'Shaughnessy M, Liedtke M. Grading cardiac response in AL amyloidosis: implications for relapse and survival. Br J Haematol 2018; 186:144-146. [PMID: 30569572 DOI: 10.1111/bjh.15717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Erik Eckhert
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Ronald Witteles
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Gregory Kaufman
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Richard Lafayette
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Sally Arai
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | - Stanley Schrier
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
| | | | - Michaela Liedtke
- Department of Medicine, Stanford University Hospital, Stanford, CA, USA
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Fukui T, Tanimura Y, Matsumoto Y, Horitani S, Tomiyama T, Okazaki K. Incidentally Detected Amyloid Light-Chain Amyloidosis Caused by Monoclonal Gammopathy of Undetermined Significance: Possible Time-Dependent Change in Colonic Findings. Case Rep Gastroenterol 2018; 12:737-746. [PMID: 30631261 PMCID: PMC6323391 DOI: 10.1159/000494919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/26/2018] [Indexed: 11/28/2022] Open
Abstract
Amyloid light-chain (AL) amyloidosis is associated with plasma cell disorder and monoclonal light chains. This type of amyloidosis is the prominent type involving the gastrointestinal tract. Monoclonal gammopathy of undetermined significance (MGUS) is the most common plasma cell disorder and a known precursor of more serious diseases. A 72-year-old male was treated for high blood pressure, diabetes, and gout at the clinic of a private physician. Due to a positive fecal occult blood test discovered during colon cancer screening, he underwent colonoscopy and was diagnosed with adenomatous polyps by biopsies. Two months later, he was referred to our hospital for endoscopic resection of the polyps. Although the polyps were successfully removed, a colonoscopy revealed two types of ulcerative lesions. Immunohistopathological evaluations obtained from these lesions and polyps confirmed amyloid deposition. Although esophagogastroduodenoscopy results were normal, a biopsy specimen from the patient's stomach showed the same type of amyloid deposition. Immunoelectrophoresis showed M-proteins for anti-IgG-λ in the serum and λ type Bence-Jones protein in the urine. His blood, bone marrow, and urine test results led to a diagnosis of MGUS. A coronary angiography revealed multivessel stenosis, and the patient's cardiac function improved after coronary artery stenting. Hereafter, a combination therapy with bortezomib, lenalidomide, and dexamethasone is planned. This is a case report of systemic AL amyloidosis caused by MGUS, which was incidentally detected by colonoscopy.
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Affiliation(s)
- Toshiro Fukui
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
| | - Yuji Tanimura
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
| | - Yasushi Matsumoto
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
| | - Shunsuke Horitani
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
| | - Takashi Tomiyama
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
| | - Kazuichi Okazaki
- Division of Gastroenterology and Hepatology, Third Department of Internal Medicine, Kansai Medical University, Hirakata, Hirakata, Japan
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Koop AH, Mousa OY, Wang MH. Clinical and endoscopic manifestations of gastrointestinal amyloidosis: a case series. ACTA ACUST UNITED AC 2018; 91:469-473. [PMID: 30564026 PMCID: PMC6296722 DOI: 10.15386/cjmed-951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 06/06/2018] [Accepted: 06/20/2018] [Indexed: 12/18/2022]
Abstract
Gastrointestinal (GI) amyloidosis is rare and has varying clinical and endoscopic presentations. In this case series, we present three patients with primary systemic amyloid-light chain (AL) amyloidosis with GI involvement and complications of GI bleeding. We also provide a brief review of the literature, including clinical presentation, endoscopic findings, pathology, and management of GI amyloidosis. The endoscopic findings of GI amyloidosis can vary, including friable mucosa with erosions, ulcers, and submucosal hematomas or mucosal thickening with polypoid protrusions. The endoscopic findings may correlate with the pathologic deposition of amyloid fibrils. Treatment of GI amyloidosis is generally focused on management of the underlying condition and supportive care. Gastroenterologists should be familiar with the endoscopic findings as they may be the first suggestion of disease and allow for definitive diagnosis.
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Affiliation(s)
- Andree Hermes Koop
- Gastroenterology and Hepatology Department, Mayo Clinic Florida, United States
| | - Omar Y Mousa
- Gastroenterology and Hepatology Department, Mayo Clinic Florida, United States
| | - Ming-Hsi Wang
- Gastroenterology and Hepatology Department, Mayo Clinic Florida, United States
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Liu YP, Jiang WW, Chen GX, Li YQ. Case report and review of the literature of primary gastrointestinal amyloidosis diagnosed with enteroscopy and endoscopic ultrasonography. World J Clin Cases 2018; 6:284-290. [PMID: 30211209 PMCID: PMC6134284 DOI: 10.12998/wjcc.v6.i9.284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 02/05/2023] Open
Abstract
Here, we report a rare case of primary gastrointestinal amyloidosis in a stable condition after being followed up for three years. The patient was admitted to the hospital in 2014. Tests showed decreased levels of hemoglobin and ferritin. Transoral and transanal enteroscopy showed multiple nodular protuberances in the esophagus, ileum, colon and rectum. Endoscopic ultrasonography indicated the nodular protuberances stemmed from the submucosa and partially invaded the intrinsic myometrium. Pathological examinations found multiple small nodules in the submucosa and dyed structures, which were positive for special Congo red dyeing. After treatment with oral iron supplements, the levels of hemoglobin and ferritin became normal. It is concluded that the patient represents a case of primary gastrointestinal amyloidosis with multiple nodular protuberances in the digestive tract with controllable moderate abdominal discomfort and anemia and a benign course. Enteroscopy and endoscopic ultrasonography play an important role in the diagnosis of primary gastrointestinal amyloidosis.
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Affiliation(s)
- Yi-Pin Liu
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan 250012, Shandong Province, China
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai 264100, Shandong Province, China
| | - Wei-Wei Jiang
- Department of Gastroenterology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai 264100, Shandong Province, China
| | - Guo-Xun Chen
- Department of Nutrition, University of Tennessee, Knoxville, TN 37996, United States
| | - Yan-Qing Li
- Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan 250012, Shandong Province, China
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Gertz MA. Immunoglobulin light chain amyloidosis: 2018 Update on diagnosis, prognosis, and treatment. Am J Hematol 2018; 93:1169-1180. [PMID: 30040145 DOI: 10.1002/ajh.25149] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/11/2018] [Accepted: 05/11/2018] [Indexed: 11/10/2022]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include restrictive cardiomyopathy, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical multiple myeloma." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for diagnosis. Invasive organ biopsy is not required because amyloid deposits can be found in bone marrow, salivary gland, or subcutaneous fat aspirate in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP), serum troponin T, and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 94.1, 40.3, 14.0, and 5.8 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Stem cell transplant (SCT) is preferred, but only 20% of patients are eligible. Requirements for safe SCT include systolic blood pressure >90 mm Hg, troponin T < 0.06 ng/mL, age < 70 years, and serum creatinine ≤1.7 mg/dL. Nontransplant candidates can be offered melphalan-dexamethasone or cyclophosphamide-bortezomib-dexamethasone. Daratumumab appears to be highly active in AL amyloidosis. Antibodies designed to dissolve existing amyloid deposits are under study. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy. EDUCATIONAL OBJECTIVES Upon completion of this educational activity, participants will be better able to: Master recognition of clinical presentations that should raise suspicion of amyloidosis. Understand simple techniques for confirming the diagnosis and providing material to classify the protein subunit. Recognize that a tissue diagnosis of amyloidosis does not indicate whether the amyloid is systemic or of immunoglobulin light chain origin. Understand the roles of the newly introduced chemotherapeutic and investigational antibody regimens for the therapy of light chain amyloidosis.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology; Mayo Clinic; Rochester Minnesota
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46
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Badar T, D'Souza A, Hari P. Recent advances in understanding and treating immunoglobulin light chain amyloidosis. F1000Res 2018; 7. [PMID: 30228867 PMCID: PMC6117860 DOI: 10.12688/f1000research.15353.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2018] [Indexed: 12/15/2022] Open
Abstract
Immunoglobulin (Ig) light chain (AL) amyloidosis is a clonal plasma cell disorder characterized by misfolded Ig light chain deposition in vital organs of the body, resulting in proteotoxicity and organ dysfunction. Owing to its diverse clinical presentations and a tendency to mimic common medical conditions, AL amyloidosis is often diagnosed late and results in dismal outcomes. Early referral to a specialized center with expertise in management of AL amyloidosis is always recommended. The availability of sensitive biomarkers and novel therapies is reforming our approach to how we manage AL amyloidosis. Treatment for patients with AL amyloidosis should be risk-adapted and customized on the basis of individual patient characteristics. In the future, approaches directed at amyloid fibril clearance in combination with agents that target plasma cells will be needed both to eradicate the malignant clone and to establish organ responses.
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Affiliation(s)
- Talha Badar
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anita D'Souza
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Parameswaran Hari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Jain T, Kosiorek HE, Kung ST, Shah VS, Dueck AC, Gonzalez-Calle V, Luft S, Reeder CB, Adams R, Noel P, Larsen JT, Mikhael J, Bergsagel L, Stewart AK, Fonseca R. Treatment With Bortezomib-based Therapy, Followed by Autologous Stem Cell Transplantation, Improves Outcomes in Light Chain Amyloidosis: A Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:486-492.e1. [DOI: 10.1016/j.clml.2018.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 04/19/2018] [Accepted: 04/27/2018] [Indexed: 11/15/2022]
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Hari P, Lin HM, Asche CV, Ren J, Yong C, Luptakova K, Faller DV, Sanchorawala V. Treatment patterns and health care resource utilization among patients with relapsed/refractory systemic light chain amyloidosis. Amyloid 2018; 25:1-7. [PMID: 29303358 DOI: 10.1080/13506129.2017.1411796] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Treatment for patients with systemic light chain (AL) amyloidosis remains challenging. Our study aims to describe treatment patterns for both newly diagnosed and relapsed/refractory AL (RRAL) amyloidosis, and to assess clinical outcomes, healthcare costs, and resource utilization during the first year following a diagnosis of RRAL amyloidsis. METHODS This was a retrospective observational study of adult patients with AL amyloidosis using the US Optum administrative claims data during 1/1/2008 to 6/30/2015. Diagnosis was based on both ICD-9 codes and treatments with a claim for AL-amyloidosis-specific anticancer systemic agents. RESULTS Of 334 patients with AL amyloidosis, 43.1% were considered as RRAL amyloidosis. The majority (75%) of RRAL amyloidosis patients had organ involvement prior to the second line treatment. Proteasome-inhibitor-based regimens were most frequently used (41.0% for first-line AL, 30.6% for RRAL amyloidosis). Organ deterioration and mortality rates were 49.3% and 10.4%, respectively, during the two years following relapse. The average monthly cost was $14,369 per patient for RRAL amyloidosis including medical costs ($9441) and drug costs ($4928). CONCLUSIONS RRAL amyloidosis is associated with high morbidity from target organ failure and mortality, which emphasizes the need for novel medications to improve care for patients with RRAL amyloidosis.
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Affiliation(s)
- Parameswaran Hari
- a Department of Medicine , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Huamao Mark Lin
- b Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge , MA , USA
| | - Carl V Asche
- c Center for Outcomes Research, Department of Medicine , University of Illinois College of Medicine at Peoria , Peoria , IL , USA.,d Center for Pharmacoepidemiology and Pharmacoeconomic Research , University of Illinois at Chicago College of Pharmacy , Chicago , IL , USA
| | - Jinma Ren
- c Center for Outcomes Research, Department of Medicine , University of Illinois College of Medicine at Peoria , Peoria , IL , USA
| | - Candice Yong
- b Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge , MA , USA
| | - Katarina Luptakova
- b Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge , MA , USA
| | - Douglas V Faller
- b Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited , Cambridge , MA , USA
| | - Vaishali Sanchorawala
- e Amyloidosis Center , Boston University School of Medicine and Boston Medical Center , Boston , MA , USA
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Zhang XD, Liu YX, Yan XW, Fang LG, Fang Q, Zhao DC, Wang YN. Cerebral embolism secondary to cardiac amyloidosis: A case report and literature review. Exp Ther Med 2017; 14:6077-6083. [PMID: 29250142 PMCID: PMC5729392 DOI: 10.3892/etm.2017.5301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/12/2017] [Indexed: 01/07/2023] Open
Abstract
Cardiac amyloidosis (CA) describes a group of heterogeneous diseases that are characterized by the extracellular fibril deposition of amyloid protein in the myocardium. The abnormal protein is usually derived from light-chain amyloidosis, mutant transthyretin amyloidosis and wild-type transthyretin. Patients with ischemic strokes and amyloidosis have been sporadically reported, however, they are not well summarized. In the present study, a case of cerebral ischemic stroke, secondary to CA was described. This patient presented with dyspnea on exertion, without any evidence of atrial fibrillation. A biopsy revealed deposition of amyloid in the myocardium and Congo Red staining was positive. He suffered from acute infarction of left basal ganglia, resulting from occlusion of the left middle cerebral arterial 6 months prior to admission. However, re-examination of cerebral magnetic resonance imaging in the present hospital revealed an old infarction in the region of the left basal ganglia with a normal appearance of the left middle cerebral artery. Transesophageal echocardiography (TEE) and cardiac magnetic resonance (CMR) both discovered intra-cardiac thrombi, confirming the diagnosis of cardiogenic cerebral embolism. The present study indicates that patients with CA may additionally present with cardiogenic cerebral embolism, and TEE and CMR imaging may help to avoid missing the presence of intra-cardiac thrombi.
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Affiliation(s)
- Xu-Dong Zhang
- Department of Respirology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Ying-Xian Liu
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Xiao-Wei Yan
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Li-Gang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Da-Chun Zhao
- Department of Pathology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
| | - Yi-Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Beijing 100730, P.R. China
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Lin Y, Marin-Argany M, Dick CJ, Redhage KR, Blancas-Mejia LM, Bulur P, Butler GW, Deeds MC, Madden BJ, Williams A, Wall JS, Dietz A, Ramirez-Alvarado M. Mesenchymal stromal cells protect human cardiomyocytes from amyloid fibril damage. Cytotherapy 2017; 19:1426-1437. [PMID: 29037943 DOI: 10.1016/j.jcyt.2017.08.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AIMS Light chain (AL) amyloidosis is a protein misfolding disease characterized by extracellular deposition of immunoglobulin light chains (LC) as amyloid fibrils. Patients with LC amyloid involvement of the heart have the worst morbidity and mortality. Current treatments target the plasma cells to reduce further production of amyloid proteins. There is dire need to understand the mechanisms of cardiac tissue damage from amyloid to develop novel therapies. We recently reported that LC soluble and fibrillar species cause apoptosis and inhibit cell growth in human cardiomyocytes. Mesenchymal stromal cells (MSCs) can promote wound healing and tissue remodeling. The objective of this study was to evaluate MSCs to protect cardiomyocytes affected by AL amyloid fibrils. METHODS We used live cell imaging and proteomics to analyze the effect of MSCs in the growth arrest caused by AL amyloid fibrils. RESULTS We evaluated the growth of human cardiomyocytes (RFP-AC16 cells) in the presence of cytotoxic LC amyloid fibrils. MSCs reversed the cell growth arrest caused by LC fibrils. We also demonstrated that this effect requires cell contact and may be mediated through paracrine factors modulating cell adhesion and extracellular matrix remodeling. To our knowledge, this is the first report of MSC protection of human cardiomyocytes in amyloid disease. CONCLUSIONS This important proof of concept study will inform future rational development of MSC therapy in cardiac LC amyloid.
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Affiliation(s)
- Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA; Human Cell Therapy Lab, Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marta Marin-Argany
- Departments of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Christopher J Dick
- Departments of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA; Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Keely R Redhage
- Departments of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Luis M Blancas-Mejia
- Departments of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Peggy Bulur
- Human Cell Therapy Lab, Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg W Butler
- Human Cell Therapy Lab, Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael C Deeds
- Human Cell Therapy Lab, Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin J Madden
- Mayo Medical Genome Facility Proteomics Core, Mayo Clinic, Rochester, MN, USA
| | - Angela Williams
- Departments of Medicine and Radiology, The University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Jonathan S Wall
- Departments of Medicine and Radiology, The University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Allan Dietz
- Human Cell Therapy Lab, Division of Transfusion Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marina Ramirez-Alvarado
- Departments of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA; Department of Immunology, Mayo Clinic, Rochester, MN, USA.
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