Ignacio Isola

CALR mutation, MPL mutation and triple negativity identify patients with the lowest vascular risk in primary myelofibrosis

CALR mutation, MPL mutation and triple negativity identify patients with the lowest vascular risk in primary myelofibrosis

Evolving M-protein pattern in patients with smoldering multiple myeloma: impact on early progression

Smoldering multiple myeloma (SMM) is a biologically heterogeneous, clinically defined entity with a variable rate of progression to symptomatic multiple myeloma (MM). Reliable markers for progression are critical for the development of potential therapeutic interventions. We retrospectively evaluated the predictive value of the evolving pattern of serum M-protein among other progression risk factors in 206 patients with SMM diagnosed between 1973 and 2012. Median time from recognition of evolving type to progression into symptomatic MM was 1.1 years (95% CI 0.5–2.0) and progression rate at 3 years was 71%. Development of the evolving type drastically worsened the prognostic estimation made at diagnosis for every covariate predictive of progression (serum M-protein size, bone marrow plasma cell infiltration, immunoparesis and Mayo Clinic risk). On average, the hazard ratio for progression to symptomatic MM increased to 5.1 (95% CI 3.4–7.6) after recognition of the evolving type. In conclusion, in patients with SMM the evolving pattern accurately predicts the risk of early progression to symptomatic disease, thereby allowing the identification of ultra-high risk patients who would be candidates for immediate therapy.

Prevalence and prognosis implication of MYD88 L265P mutation in IgM monoclonal gammopathy of undetermined significance and smouldering Waldenström macroglobulinaemia

Waldenstr€ om macroglobulinaemia (WM) is a clonal lymphoproliferative disorder characterized by the accumulation of B lymphocytes and plasma cells producing an excess of serum IgM monoclonal immunoglobulin, resulting in symptoms either from bone marrow infiltration or directly related to the paraprotein (Treon, 2009). Recent studies have shown a high frequency of the MYD88 somatic mutation L265P in patients with WM (Treon et al, 2012; Varettoni et al, 2013). The MYD88 somatic mutation L265P has been associated with disease burden and clinical features at diagnosis in patients with WM, particularly when combined with CXCR4 mutations (Treon et al, 2014). The aim of the present study was to ascertain the prevalence of MYD88 L265P mutation in individuals with IgM monoclonal gammopathy of undetermined significance (MGUS), smouldering WM (SWM) and WM patients, evaluating also its prognostic impact on progression from asymptomatic IgM gammopathies (IgM MGUS and SWM) to WM from a single institution. Ninety-eight patients (median age 70 years, range 33–92; 45 females/53 males) diagnosed with IgM MGUS, SWM or WM between May 1982 and November 2011 were retrospectively evaluated. Baseline demographics, clinical and laboratory findings were recorded, as well as treatment when required. According to the Mayo Clinic guidelines (Ansell et al, 2010), SWM was defined by a bone marrow lymphoplasmacytic infiltration over 10% and/or a serum IgM monoclonal protein ≥30 g/l, with no evidence of end-organ damage or symptoms attributed to the lymphoproliferative disorder. Patients with lower tumour burden in serum and bone marrow were classified as IgM MGUS. Progression was defined according to the International Panel Consensus (Dimopoulos et al, 2014). DNA was isolated from bone marrow slides using a commercial kit (DNeasy Blood & Tissue Kit, Qiagen, Germantown, MD, USA). MYD88 mutation L265P was analysed using quantitative real-time polymerase chain reaction (PCR) technology (qBiomarker Somatic Mutation PCR Assay, MYD88_85940, Qiagen). Briefly, allele-specific amplification is achieved by Amplification Refractory Mutation System (ARMS ) technology, which is based on the discrimination by Taq polymerase between a match and a mismatch at the 30 end of the gene. Negative and positive controls were included in each PCR plate. Statistical tests were performed with SPSS software 20 0 (IBM Corp., Armonk, NY, USA). Time to progression (TTP) and overall survival (OS) were measured in MGUS and SWM patients from diagnosis until progression or death, respectively. Survival was estimated using the Kaplan-Meir method and compared by the log-rank test. This study was approved by the Ethics Committee of the Hospital Clinic of Barcelona. The clinical characteristics of the patients are summarized in Table I. Fifty-five patients (57 1%) were classified as IgM MGUS, 30 (30 6%) as SWM and 12 as WM (12 2%). Haemoglobin levels were lower in WM (P < 0 001). Two patients with MGUS had a low haemoglobin level not related to their gammopathy. MYD88 L265P mutation was observed in 84%, 80% and 27% of WM, SWM and MGUS patients respectively. There was no difference in the detection according to light chain status. Regarding clinical characteristics according to MYD88 L265P status, there were no statistical significant differences in mean haemoglobin, lactate dehydrogenase and only a trend towards a higher serum M-protein between MGUS and SWM patients. In our 86 patients with asymptomatic IgM monoclonal gammopathies, MYD88-mutated cases showed a higher bone marrow lymphocytic infiltration (20% vs. 9%; P < 0 001) without difference in bone marrow plasma cell percentage. After a median follow-up of 4 years for surviving patients (range, 3 months to 25 years), only 5 4% of subjects with IgM MGUS (3) as compared to 23 3% with SWM (7) had developed WM (P = 0 029). Eight of the 10 patients progressing to WM carried the MYD88 L265P mutation: 2 out of 3 MGUS and 6 out of 7 SWM patients. Median TTP was longer in patients with MGUS than those with SWM (21 vs. 12 years; P = 0 001). Median OS of patients with MGUS and SWM was longer than WM cases (19 9 and 17 2 vs. 5 years; P < 0 001). Remarkably, there was a trend towards a shorter TTP in mutated vs. wild-type asymptomatic patients (median not reached vs. 22 years, P = 0 067) (Fig 1). Although it is known that the overall risk of progression to WM in IgM is approximately 1 5% per year, there are currently no clear prognostic factors to identify those patients who are at more risk (Kyle et al, 2012). Given that MYD88 L265P has been identified as a highly prevalent mutation in WM, it could be considered as the first genetic hit that promotes NF-kB and JAK-STAT3 signalling alterations. The single amino-acid mutation L265P in MYD88 Correspondence

Prognostic impact of immunoparesis at diagnosis and after treatment onset in patients with light-chain amyloidosis

Abstract Objectives: Immunoparesis (IP) is a risk factor associated with an unfavourable outcome in several plasma cell disorders. It has been suggested that its presence in light-chain (AL) amyloidosis could be associated with worse prognosis. However, the relevance of IP after treatment has not been evaluated to date. The aim of this study was to determine the prognostic impact of IP at diagnosis and one year after treatment onset in patients with AL amyloidosis. Methods: The clinical records of 69 patients with AL amyloidosis treated at a single institution from January 2006 to January 2016 were included in the study. Results: IP was observed in 27.5% of patients at diagnosis. The presence of IP was associated with a lower probability to achieve very good partial response or better after first-line treatment (37.8% versus 62.2%; p = .04). However, only in the group of patients treated with autologous stem cell transplantation (ASCT), the presence of IP resulted in a shorter progression-free survival (PFS) (30.2 months versus not reached [NR]; p = .02) but not in overall survival (OS). Persistence of IP at one year after treatment onset was identified in only four (9.8%) of the 41 evaluable patients. In the ASCT group, the absence of IP at one year after treatment onset resulted in a longer median PFS and OS (NR versus 22.6 months; p = .006; and NR versus 35.2 months; p < .001; respectively). In the multivariate analysis, the absence of IP at one year after treatment onset was independently associated with longer survival. Conclusion: IP at diagnosis has a negative impact on survival while its absence at one year after treatment is an independent marker for long-term survival.

The pattern of the M-protein in smoldering myeloma over the time: an evolving risk factor

We appreciated the comments by Lakshman et al. on our article and we have read with interest the comparison of our results in patients with evolving smoldering multiple myeloma (SMM) in Barcelona [1] with their experience at the Mayo Clinic [2]. They have risen a number of questions that allow us to further clarify and expand on specific points on our manuscript. As described in the methods section, criteria for the diagnosis of “evolving” varied with the initial M-protein concentration. Of the 47 patients with evolving pattern, the M-spike was <30 g/L in 21 (44.7%) and ≥30 g/L in 26 (55.3%). The median time to progression to symptomatic multiple myeloma (MM) of the patients belonging to these two subgroups was short, 12.2 and 6 months, respectively. We have also analyzed the absolute increase of the M component for all evolving patients from the diagnosis of the SMM at the time of finding the evolving type; this value did not allow us further predictive capacity of the evolving subtype. In the first group of patients with <30 gL, 13 had an increase of <5 g/L; the percentage of progression to MM was quite similar between both groups. As mentioned in the correspondence letter, 31, 64 and 5% of all the patients belonged to Mayo Clinic high, intermediate and low-risk categories respectively, based on the M-protein concentration and bone marrow plasma cell percentage at diagnosis. The proportion of evaluable patients with evolving pattern in each group was 25 out of 57 (43.9%), 24 out 110 (21.8%), and 2 out 9 (22.2%). Concerning the prevalence of a pre-existent monoclonal gammopathy of undetermined significance (MGUS), it was more frequent in evolving than in non-evolving patients (13 of 40 evaluable patients (32.5%) vs. 13 of 52 (25%), respectively). These values are lower than those reported in our previous publication for evolving patients (59%) [3], probably because of the smaller number of patients with an available prior serum electrophoresis in the present study. A systematic population revision would be mandatory for the unequivocal analysis of this finding. Unfortunately, and mainly due to the long time span of the study, cytogenetic data was not widely available. In a previous study of 15 SMM, we found a higher prevalence of 1q abnormalities and 13q deletion in patients with evolving pattern. In this series, we only had cytogenetic information of 18 patients, with 5 evolving patients [4]. All but one with no informative results showed normal karyotype and FISH analysis. The implementation in this group of patients of all the available cytogenetic, molecular, and epigenetic techniques potentially useful for the risk stratification of patients with monoclonal gammopathies would be of interest for further investigations. Careful evaluation of the electrophoretic pattern by two hematologists from our group allowed us to rule out spurious variations of the M-protein in those patients with <30 g/L, thereby always confirming the progressive increase in the M-protein size in consecutive measurements. As highlighted in their correspondence, the group from the Mayo Clinic has also analyzed the impact of evolving changes in M-protein and hemoglobin on progression of SMM, but they used a different definition of “evolving M-protein”. While it seems crucial to define criteria that allow an early and precise identification of the evolving behavior, it is important to recognize that the evolving changes are not present at the time of SMM diagnosis [5]. The prognostic model by Lakshman et al., [2] includes data known at time of diagnosis (i.e. percentage of plasma cells in bone marrow) and information that will not be available until later in the course of the disease (changes in the M-component and the hemoglobin level). In consequence, the model cannot be applied at the time of SMM diagnosis. In contrast, in our * Joan Bladé jblade@clinic.cat

Loss of the Immune Checkpoint CD85j/LILRB1 on Malignant Plasma Cells Contributes to Immune Escape in Multiple Myeloma

Mechanisms of immune regulation may control proliferation of aberrant plasma cells (PCs) in patients with monoclonal gammopathy of undetermined significance (MGUS) preventing progression to active multiple myeloma (MM). We hypothesized that CD85j (LILRB1), an inhibitory immune checkpoint for B cell function, may play a role in MM pathogenesis. In this study, we report that patients with active MM had significantly lower levels of CD85j and its ligand S100A9. Decreased CD85j expression could also be detected in the premalignant condition MGUS, suggesting that loss of CD85j may be an early event promoting tumor immune escape. To gain insight into the molecular mechanisms underlying CD85j functions, we next enforced expression of CD85j in human myeloma cell lines by lentiviral transduction. Interestingly, gene expression profiling of CD85j-overexpressing cells revealed a set of downregulated genes with crucial functions in MM pathogenesis. Furthermore, in vitro functional assays demonstrated that CD85j overexpression increased susceptibility to T cell– and NK-mediated killing. Consistently, ligation of CD85j decreased the number of PCs from individuals with MGUS but not from patients with MM. In conclusion, downregulation of inhibitory immune checkpoints on malignant PCs may provide a novel mechanism of immune escape associated with myeloma pathogenesis.

Bone marrow plasma cell infiltration in light chain amyloidosis: impact on organ involvement and outcome

Abstract Objectives: Prognosis of immunoglobulin light-chain (AL) amyloidosis depends mainly on the presence of cardiac involvement and the disease burden. A higher bone marrow plasma cell (BMPC) burden has been recognized as an adverse prognostic factor. The aim of our study was to analyze the correlation between the BMPC infiltration, clinical features and outcomes in patients with AL amyloidosis. Methods: The clinical records of 79 patients with AL amyloidosis treated at a single institution. Results: Median BMPC infiltration at diagnosis was 11% and significantly correlated with the serum free light-chain difference (p < .001). Patients with more than 10% BMPCs had more frequent cardiac involvement (86 vs. 63%; p = .015), a trend towards a higher early mortality (27 vs. 11%; p = .08) and a significantly shorter progression-free survival (PFS) (median of 18 vs. 48 months, p = .02) and overall survival (median of 33 months vs. not reached; p = .046). In the multivariate analysis, a BMPC infiltration over 10% retained its adverse prognostic value for PFS (HR = 2.26; 95% CI, 1.048–4.866; p = .038). The use of new drugs seemed to overcome the negative prognostic impact of a higher BMPC infiltration. Conclusion: Higher BMPC infiltration in AL amyloidosis might be associated with increased systemic organ damage, particularly cardiac involvement and is rarely related to the development of myeloma features.

Absence of spontaneous response improvement beyond day |[plus]|100 after autologous stem cell transplantation in multiple myeloma

The response evaluation after autologous stem-cell transplantation (ASCT) is usually performed at day +100 in patients with multiple myeloma (MM). A recent report suggests that improvement in the response can be observed beyond day +100. The aim of the present study has been to evaluate the rate of improved response and outcome beyond day +100 after ASCT, with and without maintenance therapy. One hundred and forty-four patients who underwent single ASCT with chemosensitive disease and achieved less than CR at day 100 post ASCT were evaluated. Seventy-four patients (51.4%) did not receive any maintenance with only one of them showing an upgrade in the response. The remaining 70 patients (48.6%) received maintenance therapy; eleven of them (15.7%) improved their response beyond day +100. The outcome of these patients was better than those who did not upgrade their response in both progression-free survival and overall survival (P=0.019 and P=0.031, respectively). In conclusion, the improvement in response beyond day +100 after ASCT in patients not receiving any therapy is exceedingly rare. A minority of patients receiving maintenance therapy after ASCT upgrades their response and this finding is associated with better outcome.