Kaini Shen

Risk of Multiple Myeloma in Rheumatoid Arthritis: A Meta-Analysis of Case-Control and Cohort Studies

Objectives multiple myeloma is a malignant neoplasm of plasma cells mainly affecting elderly patients. Despite the wealth of information available on therapeutic strategies, the etiology and pathogenesis of myeloma remain unclear. In the current study, a meta-analysis was conducted to assess the possible association between rheumatoid arthritis and myeloma. Methods a literature search was conducted with PubMed, EMBASE and Web of Science for relevant studies published by December 25, 2013. Additionally, we searched annual meeting abstracts of the American Society of Hematology from 2004 to 2013. Only original studies that investigated the association between rheumatoid arthritis and myeloma were included. In total, 8 case-control and 10 cohort studies were identified for analysis. Results the meta-estimate of the association between rheumatoid arthritis and myeloma was 1.14 (95% CI, 0.97–1.33) overall, with significant heterogeneity among studies. The relationship between myeloma and other autoimmune diseases was additionally examined from available data. Our results showed that myeloma risk is increased 1.31 to 1.65-fold in pernicious anemia and 1.36 to 2.30-fold in ankylosing spondylitis patients. Conclusion Rheumatoid arthritis does not appear to alter the risk of myeloma, while between-study heterogeneity analyses suggest caution in the interpretation of results. Pernicious anemia and ankylosing spondylitis may be potential risk factors for myeloma development. Future large-scale epidemiological studies with reliable exposure biomarkers are necessary to establish the possible contribution of autoimmune disorders to multiple myeloma.

The clinical spectrum of IgM monoclonal gammopathy: A single center retrospective study of 377 patients.

OBJECTIVES We retrospectively evaluated the clinical features, serum levels of IgM, and prevalence of IgM related diseases in patients with serum immunofixation electrophoresis (sIFE) confirmed IgM monoclonal gammopathy at our center. METHODS We included patients with sIFE confirmed IgM monoclonal gammopathy between January 2008 and December 2014 in this retrospective study. We evaluated clinical data, sIFE, serum IgM levels, and diagnosis. RESULTS In total, 7107 patients had sIFE confirmed monoclonal gammopathy, with 377 (5.3%) patients having the IgM type. The median age was 62 years (range, 19-105 years). The median level of serum IgM is 8.3g/L (range, 0.24-150g/L). The diagnosis included monoclonal gammopathy of undetermined significance (MGUS, 157 patients, 41.6%), Waldenstrom macroglobulinemia (WM, 105 patients, 27.9%), B cell non-Hodgkins lymphoma (69 patients, 18.3%), primary cold agglutinin disease (pCAD, 16 patients, 4.2%), primary amyloidosis (14 patients, 3.7%), cryoglobulinaemia (six patients, 1.6%), IgM MGUS associated neuropathy (five patients, 1.3%), multiple myeloma (three patients, 0.8%), and POEMS syndrome (two patients, 0.5%). Levels of serum IgM>15.5g/L were 80.6% sensitive and 89.2% specific for the diagnosis of WM. Kappa type light chain indicated the diagnosis of WM, pCAD, IgM MGUS associated neuropathy and cryoglobulinaemia, while lambda type light chain indicated POEMS and amyloidosis. There were 41/157 (26.1%) MGUS patients diagnosed with complications due to IgM-unrelated autoimmune diseases. CONCLUSION IgM monoclonal gammopathy contains a broad spectrum of diseases. Levels of serum IgM and the type of light chain can be used to help with differential diagnosis. The association between MGUS and some autoimmune diseases requires further investigation.

14q32 translocations and 13q14 deletions are common cytogenetic abnormalities in POEMS syndrome.

POEMS syndrome is a paraneoplastic syndrome characterized by polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell (PC) proliferative disease, and skin changes. Although chromosomal aberrations have been found and extensively described for other PC disorders, whether POEMS syndrome shares similar cytogenetic profiles has been rarely reported. In this study, we aimed to clarify the cytogenetic abnormalities of patients with POEMS syndrome in our center.

Comparison of Different Buffers for Protein Extraction from Formalin-Fixed and Paraffin-Embedded Tissue Specimens.

We determined the best extraction buffer for proteomic investigation using formalin-fixation and paraffin-embedded (FFPE) specimens. A Zwittergent 3–16 based buffer, sodium dodecyl sulfate (SDS)-containing buffer with/without polyethylene glycol 20000 (PEG20000), urea-containing buffer, and FFPE-FASP protein preparation kit were compared for protein extraction from different types of rat FFPE tissues, including the heart, brain, liver, lung, and kidney. All of the samples were divided into two groups of laser microdissected (LMD) and non-LMD specimens. For both kinds of specimens, Zwittergent was the most efficient buffer for identifying peptides and proteins, was broadly applicable to different tissues without impairing the enzymatic digestion, and was well compatible with mass spectrometry analysis. As a high molecular weight carrier substance, PEG20000 improved the identification of peptides and proteins; however, such an advantage is limited to tissues containing submicrograms to micrograms of protein. Considering its low lytic strength, urea-containing buffer would not be the first alternative for protein recovery. In conclusion, Zwittergent 3–16 is an effective buffer for extracting proteins from FFPE specimens for downstream proteomics analysis.

The Successful Diagnosis and Typing of Systemic Amyloidosis Using A Microwave-Assisted Filter-Aided Fast Sample Preparation Method and LC/MS/MS Analysis

Laser microdissection followed by mass spectrometry has been successfully used for amyloid typing. However, sample contamination can interfere with proteomic analysis, and overnight digestion limits the analytical throughput. Moreover, current quantitative analysis methods are based on the spectrum count, which ignores differences in protein length and may lead to misdiagnoses. Here, we developed a microwave-assisted filter-aided sample preparation (maFASP) method that can efficiently remove contaminants with a 10-kDa cutoff ultrafiltration unit and can accelerate the digestion process with the assistance of a microwave. Additionally, two parameters (P- and D-scores) based on the exponentially modified protein abundance index were developed to define the existence of amyloid deposits and those causative proteins with the greatest abundance. Using our protocol, twenty cases of systemic amyloidosis that were well-typed according to clinical diagnostic standards (training group) and another twenty-four cases without subtype diagnoses (validation group) were analyzed. Using this approach, sample preparation could be completed within four hours. We successfully subtyped 100% of the cases in the training group, and the diagnostic success rate in the validation group was 91.7%. This maFASP-aided proteomic protocol represents an efficient approach for amyloid diagnosis and subtyping, particularly for serum-contaminated samples.

Autologous stem cell transplant can overcome poor prognosis in patients with multiple myeloma with extramedullary plasmacytoma

Multiple myeloma (MM) is a malignant condition of plasma cells, usually confi ned to the bone marrow. Under certain circumstances, extramedullary plasmacytomas (EMPs) may develop as a result of direct spread from the bone or hematogenous metastasis. About 7 – 18% of newly diagnosed myelomas are complicated by plasma cell tumors outside the bone marrow, with an additional incidence of EMP of 20% later during the course of the disease [1 – 4]. In spite of the increasing incidence of extramedullary disease, few studies have investigated the clinical features and prognosis of MM with EMP. Varettoni et al . [1], Wu et al . [2] and Usmani et al . [5] demonstrated that patients with MM without extramedullary involvement had better long-term outcomes than those with EMPs. However, these studies did not restrict the treatment strategy. Since transplant has become fi rst-line therapy for MM in patients younger than 65 years, the use of high-dose therapy (HDT) may be promising for patients with MM with EMP. Th erefore we conducted a retrospective analysis of patients with MM with EMP at the time of their initial diagnosis and investigated the eff ect of autologous stem cell transplant (ASCT) on their prognosis. One hundred and forty-nine patients with MM who underwent ASCT from 1 January 2005 to 31 December 2011 were included. Of these, 28 had confi rmed EMP when MM was initially diagnosed, which was defi ned as a mass of neoplastic monoclonal plasma cells in the soft tissue surrounding the bones or extraosseous organs, while solitary and bony plasmacytomas were excluded. Myeloma response and relapse before or after transplant were assessed based on the European Group for Blood and Marrow Transplantation (EBMT) criteria. Diff erences in continuous and dichotomous variables were tested by Student ’ s t -test and χ 2 test, respectively. Improvements of response status after ASCT were evaluated through the McNemar test. All tests were two-sided with p -values of less than 0.05 considered to be statistically signifi cant. Survival curves were plotted according to the method of Kaplan and Meier, and between-group comparisons of progression-free survival (PFS) and overall survival (OS) were done with the log-rank test. Prognostic factors for PFS and OS were analyzed by a Cox proportional hazards model. Twenty-eight of 149 patients had extramedullary involvement at the initial diagnosis of MM (median age 53.5 years, male/female 1:1). Table I outlines the clinical and laboratory features of patients with EMP. Soft tissue masses arising from the bone were most common (82.1%), including vertebrae (39.3%), rib (14.3%), clavicle (7.1%), inferior maxilla (7.1%), maxillae (3.6%), pelvis (3.6%), sternum (3.6%) and sternoclavicular joint (3.6%). Other locations with hematogenous spread included the pleura ( n 1), mediastinum ( n 1), liver ( n 2) and stomach ( n 1). Extramedullary involvement was found to be associated only with lower International Staging System (ISS) stage at the time of diagnosis of MM ( p 0.003). In the EMP group, most patients (71.4%) received a bortezomib-based regimen as induction chemotherapy. Sixteen (57.1%) patients in the EMP group and 82 (70.7%, response status of fi ve patients unknown) in the non-EMP group achieved at least a very good partial response (VGPR) ( p 0.168). EMP in 19 (67.9%) patients with MM disappeared after induction; 14 of them received bortezomib-based frontline therapy and the response rate of extramedullary disease to bortezomib-based therapy reached 70%. All patients underwent ASCT after induction chemotherapy with a conditioning regimen of melphalan alone or melphalan plus bortezomib. Ruling out the two patients with unknown response status, the two groups responded comparably well to HDT, with 46.6% complete response (CR), 35.7%

Successful treatment of refractory Sezary syndrome by anti-PD-1 antibody (nivolumab).

Dear Editor, Advanced-stage Sezary syndrome (SS) is a poor prognostic primary cutaneous T cell lymphoma (pCTCL) with a median survival of 1–5 years [1]. We report a case of relapsed and refractory SS who had a favorable response to anti-PD-1 antibody. A 67-year-old male was followed for 7 years due to histologically proven SS (T4N3M1B1). The following treatments were attempted: PUVA; cyclophosphamide, doxorubicin, vincristine, and prednisone; methotrexate, bortezomib, gemcitabine, lenalidomide, and chidamide. The disease continued to progress with diffuse exfoliative erythroderma, thickening of the skin, accompanied by uncontrollable pruritus and paresthesia, hepatosplenomegaly, and lymphadenopathy. The blood smear showed 20% Sezary cells. Peripheral blood flow cytometry showed immunophenotypically abnormal CD4+ T cells with CD3, CD5, and CD25 expression accounting for 98% of the total lymphocytes. The decision was made to adopt nivolumab, an antiPD-1 antibody. Two days after administration (3 mg/kg), the patient had fever to 39.0 °C, progressive blisters involving the extremities, and an exfoliative rash covering >80% body surface (Fig. 1a–c). The IL-6 and TNF-α increased to 104.0 pg/mL (reference range, 0–5.9) and 672.0 pg/mL (reference range, 0–8.1). One week after treatment with nivolumab, the cutaneous symptoms worsened with further development of mucosal lesions; thus, intravenous methylprednisolone (0.8 mg/kg/d) was started and skin toxicity improved remarkably. The IL-6 and TNF-α levels gradually declined to normal, and steroids were tapered rapidly over 2 weeks. Three additional cycles of nivolumab were given without any adverse effects. Notably, regression of skin thickening and plaques were observed (Fig. 1d–f), and pruritus was significantly relieved. His mSWAT score decreased from 118 to 40. The inguinal node size decreased, and Sezary cells were cleared in the peripheral blood. The T lymphocyte subset revealed a remarkably decrease in CD4+ T cells (183/μL). A global partial response was confirmed, and treatment with nivolumab (3 mg/kg every 4 weeks) is currently ongoing. No progression has been observed during the following 6 months. Targeting the PD-1-PD-ligand 1 axis has shown promise in patients with non-Hodgkin lymphoma [2]. Unfortunately, in a phase I study [3], two patients with SS failed to achieve a response. The current patient had a marked improvement in erythroderma and pruritus and a decrease in the Sezary cells. The pathophysiologic mechanism governing dermatologic toxicities of anti-PD-1 antibody might be similar to cytokine release syndrome (CRS) [4], which is observed in patients receiving chimeric antigen receptor (CAR) T cells. The hallmark of CRS is immune activation, resulting in elevated inflammatory cytokine levels and organ toxicity. The severity of CRS is related to the disease burden at the time of CAR T cell infusion [5]. Our patient had severe skin toxicity during the first cycle when the tumor burden was the highest

[Classification of amyloidosis by laser micro-dissection and mass spectrometry based proteomic analysis].

目的 评估利用激光显微切割联合质谱蛋白质组学技术对系统性淀粉样变性进行分型的有效性。 方法 以138例病理确诊为淀粉样变性患者的经福尔马林固定石蜡包埋标本为研究对象。利用显微切割收集刚果红染色阳性区域组织并行质谱蛋白质组学分析，以指数修正的蛋白质丰度指标(emPAI)为标准，根据丰度最高的致淀粉样变蛋白判定淀粉样变性亚型。 结果 在138份组织标本中，腹壁脂肪占26%，舌体占19%，齿龈占11%，肾脏占9%，胃肠道占9%，心脏占6%，其余类型样本占20%。总共121例患者获得成功分型，包括轻链型106例(87.6%)，遗传性甲状腺转运球蛋白型7例(5.8%)，致淀粉样变蛋白A型、重链/重链+轻链型及纤维蛋白原α链型各2例(1.7%)，载脂蛋白A-Ⅱ型及溶菌酶型各1例(0.8%)。5例被排除淀粉样变性诊断，12例分型失败。总体诊断准确率为91.3%。在各种组织类型标本中，腹壁脂肪组织的分型成功率最低，仅为83.3%。 结论 激光显微切割联合质谱蛋白质组学方法能有效鉴定出淀粉样变性亚型。OBJECTIVE To establish a novel method to determine specific type of amyloidosis through laser microdissection and mass spectrometry (LMD/MS) based proteomic analysis. METHODS There were 138 formalin-fixed and paraffin-embedded (FFPE) biopsy samples of patients who were diagnosed as systemic amyloidosis used in this study. For each case, a 10 μm section stained with congo-red and positive amyloid deposits were identified under fluorescent light, followed by micro-dissection and mass spectrometry analysis. The amyloidosis subtype was confirmed based on the most abundant amyloid protein. RESULTS The tissue types of 138 specimens were as following: subcutaneous abdominal fat accounted for 26%, tongue for 19%, gingiva for 11%, kidney for 9%, intestine for 9%, heart for 6% and others for 20%. Specific types of amyloid were accurately detected in 121 cases, including 106 (87.6%) amyloid light chain (AL) type, 7 (5.8%) amyloid trans-thy-retin (ATTR), 2 (1.7%) amyloidogenic protein A (AA), 2 (1.7%) amyloid heavy chain (AH)/AL+AH, 2 (1.7%) fibrinogen alpha chain (AFib), 1(0.8%) amyloid apolipoprotein A-type II (AApoA-II) and one (0.8%) amyloid lysozyme (ALys). Diagnosis of amyloidosis was excluded in 5 cases. The types of twelve cases were indeterminate by LMD/MS. On the whole, LMD/MS reached 91.3% accuracy rate in amyloid typing. Commonly involved organs (for example, heart, kidney and liver) turned out to be suitable sources of FFPE samples with typing success rate of almost 100%. In contrast, MS analysis was successful in only 83.3% of subcutaneous abdominal fat samples. CONCLUSION LMD/MS method provided a more direct technique for accurate typing of amyloidosis in a single procedure.