Concomitant Myelofibrosis and Plasma Cell Disorders: The Mayo Clinic Experience.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3603-3603
Author(s):  
Ruben A. Mesa ◽  
S. Vincent Rajkumar ◽  
Susan Schwager ◽  
Rebecca McClure ◽  
Heather Powell ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Clinical Manifestations ◽  
Staging System ◽  
Clinical History ◽  
Plasma Cell Dyscrasia ◽  
Consecutive Series ◽  
Myeloid Metaplasia ◽  
Plasma Cell Disorders

Abstract BACKGROUND: Bone marrow fibrosis might represent either a primary myeloid malignancy such as myelofibrosis with myeloid metaplasia (MMM) or a reactive phenomenon associated with other malignancies or inflammatory/infectious processes. The development of myelofibrosis in the context of a plasma cell dyscrasia is uncommon and incompletely understood from the standpoint of both pathogenesis and clinical implications. We sought to determine the origin and clinical ramifications of this phenomenon based on a consecutive series of patients with plasma cell disorders (PCD). METHODS: A retrospective search of institutional databases was performed for clinical cases of PCD with the concomitant observation of myelofibrosis. Bone marrow aspirates and trephines from the time of diagnosis of both PCD and myelofibrosis were reviewed. Clinical history was abstracted for clinical manifestations as well as disease course. DNA from archived cytogenetic pellets, when available, from the time of diagnosis, was screened for the presence of JAK2V617F. RESULTS: Among 7587 patients with a PCD seen over the last 30 years at our institution, 29 (0.3%) displayed concomitant myelofibrosis (median age 59 years, range 27–77; 52% males). The specific PCD was multiple myeloma in 25 patients, smoldering myeloma in 2, plasmacytoma in 1, and heavy chain disease in 1. Four patients (14%) had organomegaly and bone marrow histological features most consistent with MMM. Otherwise, myeloproliferative disorder (MPD)-characteristic features were infrequent and included leukocytosis and/or thrombocytosis in only 2 patients. None of the patients displayed thrombohemorrhagic complications. Archived DNA was available in 7 cases without either clinical or bone marrow histological evidence of a MPD and yet revealed the presence of JAK2V617F in 6 of the 7 cases (86%). In addition, one other patient without MPD phenotype displayed a monosomy 5 abnormality. To date, 2 patients, one with and one without a MPD phenotype underwent leukemic transformation. All other causes of death were related to PCD-associated complications. Median survival (Kaplan-Meier) for the patients with multiple myeloma was 50 months. Survival stratified by the myeloma international staging system (ISS) was similar or better than expected (published controls of 62, 44, and 29 months): median survivals for this series of 73, 51 and 37 months for stage I, II, and III disease, respectively. CONCLUSIONS: Myelofibrosis that accompanies a PCD often represents an underlying MPD and does not negatively impact the natural history of the associated PCD.

scholarly journals Levels of CEACAM6 in Peripheral Blood Are Elevated in Patients with Plasma Cell Disorders: A Potential New Diagnostic Marker and a New Therapeutic Target?

2019 ◽  
Vol 2019 ◽  
pp. 1-6
Author(s):  
N. Steiner ◽  
R. Hajek ◽  
D. Nachbaur ◽  
B. Borjan ◽  
S. Sevcikova ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Adhesion Molecule ◽  
Peripheral Blood ◽  
Therapeutic Target ◽  
Plasma Levels ◽  
Diagnostic Marker ◽  
Healthy Controls ◽  
Plasma Cell Disorders

Introduction. The prognosis of multiple myeloma is still unfavorable due to inherent characteristics of the disease and the often-delayed diagnosis due to widespread and unspecific symptoms such as back pain and fatigue. Therefore, a simple diagnostic blood test would be helpful to speed up the diagnostic procedure in such patients (pts.). Here, we evaluated the diagnostic value of plasma levels of carcinoembryonic antigen-related cell adhesion molecule 6 (CEACAM6) in the peripheral blood and bone marrow of pts. with plasma cell disorders and in healthy controls. Materials and Methods. Immunoreactive CEACAM6 was determined in the peripheral blood and bone marrow (n=95/100) of pts. with monoclonal gammopathy of unknown significance (MGUS: 28/37), newly diagnosed multiple myeloma (NDMM: 42/40), and relapsed/refractory multiple myeloma (RRMM: 25/23) by sandwich ELISA. Results. Median CEACAM6 levels in the peripheral blood of pts. with plasma cell disorders were significantly higher than those of healthy controls (healthy controls: 15.2 pg/ml (12.1-17.1); MGUS: 19.0 pg/ml (16.4-22.5); NDMM: 18.0 pg/ml (13.4-21.2); and RRMM: 18.9 pg/ml (15.2-21.5); p<0.001). Plasma levels of CEACAM6 discriminated healthy subjects from MGUS/NDMM pts. (AUC=0.71, 95% CI: 0.6-0.8); i.e., a CEACAM6 level>17.3 pg/ml has an 82% (95% CI: 70-90) predictive probability for the identification of MGUS or NDMM. Moreover, CEACAM6 levels in the bone marrow were significantly higher in RRMM pts. than in NDMM pts. (p=0.04), suggesting a role of this molecule in disease progression. Conclusion. CEACAM6 plasma levels can noninvasively identify pts. with a plasma cell disorder and should be evaluated prospectively as a potential diagnostic marker. Moreover, due to high CEACAM6 levels in the bone marrow in RRMM pts., this adhesion molecule might be a therapeutic target in multiple myeloma pts.

Secretome Analyses of Primary Bone Marrow Fibroblasts Isolated From MGUS and Multiple Myeloma Show a Stepwise Occurrence of Alterations.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1801-1801
Author(s):  
Johannes Drach ◽  
Astrid Slany ◽  
Thomas Mohr ◽  
Johannes Griss ◽  
Christoph C Zielinski ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Growth Factor ◽  
Plasma Cell ◽  
Conflicts Of Interest ◽  
Cell Clone ◽  
Serum Levels ◽  
Plasma Cell Dyscrasia ◽  
Healthy Donors ◽  
Bone Marrow Fibroblasts

Abstract Abstract 1801 Poster Board I-827 The microenvironment of tumor cells in the bone marrow was demonstrated to contribute to tumor promotion and survival. The role of bone marrow fibroblasts (BMFs) in supporting the malignant plasma cell clone in multiple myeloma (MM) has been established, but it remains unclear to which extent the BM microenvironment in general and BMFs in particular are involved in the progression of monoclonal gammopathy of undetermined significance (MGUS) to MM. Therefore we performed proteomics studies on the secretome of BMFs isolated from healthy donors, patients suffering from MGUS and patients suffering from MM. Compared to normal background, BMFs derived from MGUS secreted elevated levels of proteins indicating mitogenic activity and moderate inflammation. These proteins included periostin, IL-6, CXCL5 and CSF-1. Insulin-like growth factor II, which is normally not expressed by normal BMFs, was secreted by BMF cells derived from MGUS as well as from MM. In addition to those and other proteins, BMF cells derived from MM were found to specifically secrete stem cell growth factor, MMP-28 and stanniocalcin-1. These data indicate a step-wise alteration of BMF secretion activity related to the stage of the underlying plasma cell dyscrasia. Therefore BMF might support the progression from MGUS to MM. In order to correlate the secretion performance of BMF with blood serum levels of candidate marker proteins, Luminex assays are employed. Based upon these results, it is our aim to identify serum biomarkers which allow to assess the functional state of BMF and thus the risk for the progression of MGUS to MM. Disclosures No relevant conflicts of interest to declare.

scholarly journals Full-length immunoglobulin high-throughput sequencing reveals specific novel mutational patterns in POEMS syndrome

2019 ◽  
Author(s):  
Sébastien Bender ◽  
Vincent Javaugue ◽  
Alexis Saintamand ◽  
Maria Victoria Ayala ◽  
Mehdi Alizadeh ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Plasma Cell ◽  
High Throughput ◽  
High Throughput Sequencing ◽  
Clinical Manifestations ◽  
Diagnostic Value ◽  
Poems Syndrome ◽  
Full Length ◽  
Plasma Cell Dyscrasia ◽  
Multisystem Disease

AbstractPOEMS syndrome is a rare multisystem disease due to an underlying plasma cell (PC) dyscrasia. The pathophysiology of the disease remains unclear but the role of the monoclonal immunoglobulin (Ig) light chain (LC) is strongly suspected, due to the highly restrictive usage of two λ variable (V) domains (IGLV1-40 and IGLV1-44) and the general improvement of clinical manifestations following PC clone-targeted treatment. However, the diagnostic value of Ig LC sequencing, especially in case of incomplete forms of the disease, remains to be determined. Using a sensitive high-throughput Ig repertoire sequencing on RNA (RACE-RepSeq), we detected a λ LC monoclonal expansion in the bone marrow (BM) of 85% of patients with POEMS syndrome, including some in whom bone marrow tests routinely performed to diagnose plasma cell dyscrasia failed to detect λ+ monoclonal PCs. Twenty-four of the 30 LC clonal sequences found (80%) were derived from the IGLV1-40 and IGLV1-44 germline genes, two from the closely related IGLV1-36 gene, and all were associated with an IGLJ3*02 junction (J) gene, confirming the high restriction of VJ region usage in POEMS syndrome. RACE-RepSeq VJ full-length sequencing additionally revealed original mutational patterns, the strong specificity of which might crucially help establish or eliminate the diagnosis of POEMS syndrome in uncertain cases. Thus, RACE-RepSeq appears as a sensitive, rapid and specific tool to detect low-abundance PC clones in BM, and assign them to POEMS syndrome, with all the consequences for therapeutic options hereby.

Frequency and Prognostic Relevance of Cancer Testis Antigen 45 Expression in Multiple Myeloma

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 5134-5134
Author(s):  
Valeria C.C. Andrade ◽  
Gisele W. B. Colleoni ◽  
Andre Luiz Vettore ◽  
Maria R. R. Silva ◽  
Roberta Spetic Felix ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Multiple Myeloma ◽  
Bone Marrow ◽  
Cell Line ◽  
Plasma Cell ◽  
Cell Morphology ◽  
Staging System ◽  
Monoclonal Gammopathies ◽  
Normal Tissues ◽  
Cancer Testis

Abstract Introduction: Cancer testis (CT) antigens have become the most extensively studied antigen group in the field of tumor immunology. CT45 antigen expression was described in colon adenocarcinomas, germ cell tumors, Hodgkin’s lymphomas and, more recently, in multiple myeloma (MM). Aims: This study aims to analyze the expression of CT45 in normal tissues and in plasma cell disorders and to identify possible associations with clinical data and prognosis in MM. Patients and Methods: The expression of CT45 was studied in twenty normal tissues (testis, placenta, skeletal muscle, bladder, lung, spleen, heart, brain, fetal brain, thymus, uterus, stomach, mammary gland, pancreas, prostate, small intestine, kidney, adrenal gland, spinal cord, colon and one pool of ten normal bone marrow samples) and in bone marrow aspirates from three monoclonal gammopathies of undetermined significance (MGUS), five solitary plasmacytomas, 61 newly diagnosed MM patients and MM cell line U266 by RT-PCR. Results: CT45 was positive in three out of 20 (15%) normal tissues tested: lung, brain (both fetal and adult) and spinal cord. Among monoclonal gammopathies, CT45 was positive in two out of five (40%) solitary plasmacytomas’ bone marrow aspirates, 10 out of 61 (16%) MM bone marrow aspirates and in the U266 MM cell line. Six out of 10 (60%) CT45 positive MM cases were classified as International Staging System (ISS) 3 (p = 0.009). Six CT45-positive cases were classified as plasmacytic (PC) and four as polymorphic (PM). Median OS of the MM group was 21 months. Nine patients were submitted to autologous stem cell transplantation. All of the transplanted cases were CT45-negative. Univariate analysis showed that Durie-Salmon Staging System (Durie-Salmon IIIA: N = 35, median OS = 40 months; Durie-Salmon IIIB: N = 19, median OS = 12 months; log-rank p= 0.0139), b2microglobulin (b2microglobulin £ 5.5 mg/L: N = 27, median OS = 40 months; b2microglobulin &gt; 5.5 mg/L: N = 24, median OS = 12 months, log-rank p= 0.0520, Breslow p = 0.0352, Tarone-Ware p = 0.0399), plasma cell morphology (PC: N = 38, median OS = not reached; PM: N = 11, median OS = 12 months; PB: N = 5, median OS = 1 month; log-rank p= 0.0037), transplantation proceedings (transplanted patients: N = 9, median OS = not reached; non-transplanted patients: N = 47, median OS = 14 months; p = 0.0064) and CT45 expression (CT45 expression negative: N = 46, median OS = 25 months; CT45 expression positive: N = 10, median OS = 3 months, log-rank p = 0.038 for all patients and CT45 expression negative: N = 37, median OS = 19 months; CT45 expression positive: N = 10, median OS = 3 months, p = 0.0245, only non-transplanted patients) had impact on OS. Cox Regression Model showed that only plasma cell morphology (p = 0.029, RR 5.288, CI 1.77704–15.7988), transplant proceedings (p = 0.0742, RR 0.1582, CI 0.0209–1.1976) and CT45 expression (p = 0.0016, RR 7.0403, CI2.0978–23.6278) were independent prognostic factors in MM patients survival. CT45-positive cases were associated with poor outcome and presented 7 times more chance of worse evolution then the negative ones. Conclusions: CT45 was expressed in only 16% of MM patients. However, we demonstrated for the first time that positive expression of CT45 was associated with high ISS scores and poor outcome in MM

CD81: A Novel, Specific and Highly Sensitive Marker in Flow Cytometric Diagnosis of Plasma Cell Dyscrasia

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2880-2880
Author(s):  
Prashant Ramesh Tembhare ◽  
Constance Yuan ◽  
Neha Korde ◽  
Irina Maric ◽  
Katherine Calvo ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Plasma Cells ◽  
Conflicts Of Interest ◽  
Antigen Expression ◽  
Plasma Cell Dyscrasia ◽  
Fluorescent Intensity ◽  
Reliable Marker ◽  
Sensitive Marker

Abstract Abstract 2880 Background: The percent abnormal plasma cells (aPC) as determined by flow cytometry (FC) has been shown to be an independent risk factor for progression from myeloma precursor disease (monoclonal gammopathy of uncertain significance, MGUS; smoldering multiple myeloma, SMM) to multiple myeloma (MM). However, differentiation of aPCs from normal PCs (nPCs) in these patients is challenging. MM cell lines are know to underexpress the tetraspanin proteins (e.g. CD81, CD82) in comparison to nPCs. Although CD81, a nonglycosylated tetraspanin, is robustly expressed on the surface of nPCs, little information is available regarding its expression in the aPCs of MM, SMM and MGUS. In this study we evaluate the expression of CD81 in conjunction with CD19, CD45 and CD56 in bone marrow aPCs and nPCs from patients with MM, SMM and MGUS. Methods: Bone marrow aspirates from 41 patients (9 MGUS, 22 SMM, 7 MM, 3 non-neoplastic with clinical suspicion of MGUS) were analyzed with 8-color multiparametric FC using a panel of antibodies (CD138, CD38, CD19, CD20, CD27, CD28, CD45, CD56, CD81, CD13, CD14, CD16, CD3, CD34 and intracellular kappa & lambda light chains). The pattern of surface antigen and intracellular light chain expression was utilized to determine the percent aPC (defined as monoclonal with aberrant antigen expression) and percent nPC (defined as polyclonal with normal antigen expression). In all cases the pattern of antigen expression was evaluated in the aPCs; additionally, in cases with greater than 5% nPCs (19/41 patients: 8 MGUS, 8 SMM and 3 non-neoplastic) the pattern of antigen expression was evaluated in the nPCs. The ability to detect clonal aPC by evaluation of FC pattern of antigen expression was determined and compared for CD19, CD45, CD56 and CD81. We also examined the sensitivity and specificity of the CD19 and CD81 combination verses the conventional combination of CD19, CD56 and CD45 (Perez-Persona et al, Blood 2007) for the detection of clonal aPC. Results: CD81 was strongly expressed by nPC (average mean fluorescent intensity (MFI): 11500, standard deviation (SD): 5061, range: 5347–21657) in contrast to aPC with abnormally weak expression (average MFI: 1487, SD: 887, range: 647–4311). CD81 was a highly reliable marker for the detection of clonal PC; with 90% sensitivity and 100% specificity. It was the most specific and second most sensitive marker in our study (Table 1). CD81 was equally sensitive in detection of aPCs in MGUS, SMM and MM. Evaluation of the combined pattern of expression of CD19 and CD81 resulted in 100% sensitivity and 100% specificity for detection of aPC, which is greater than the conventional combination of CD19, CD56 and CD45, yielding 100% sensitivity but 90% specificity, for diagnostic evaluation of aPC. Conclusions: CD81 is a highly reliable marker in the detection of abnormal plasma cells in MM, SMM and MGUS. The combined approach of CD19 and CD81 is superior to other conventional marker combinations (i.e. CD19, CD45, and CD56) in terms of detection of clonal plasma cells and may replace their use in the clinical evaluation of bone marrow aspirates for plasma cell processes. Furthermore, it should help widening the applicability of minimal residual disease testing in MM. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Monoclonal gammopathy of undetermined significance

Blood ◽  
2019 ◽  
Vol 133 (23) ◽  
pp. 2484-2494 ◽  
Author(s):  
Tarek H. Mouhieddine ◽  
Lachelle D. Weeks ◽  
Irene M. Ghobrial
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Monoclonal Gammopathy ◽  
Cell Clone ◽  
Plasma Cell Dyscrasia ◽  
Bone Marrow Niche ◽  
Immunologic Factors ◽  
Risk Of Progression ◽  
Undetermined Significance

Abstract Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant plasma cell dyscrasia that consistently precedes multiple myeloma (MM) with a 1% risk of progression per year. Recent advances have improved understanding of the complex genetic and immunologic factors that permit progression from the aberrant plasma cell clone to MGUS and overt MM. Additional evidence supports bidirectional interaction of MGUS cells with surrounding cells in the bone marrow niche that regulates malignant transformation. However, there are no robust prognostic biomarkers. Herein we review the current body of literature on the biology of MGUS and provide a rationale for the improved identification of high-risk MGUS patients who may be appropriate for novel clinical interventions to prevent progression or eradicate premalignant clones prior to the development of overt MM.

A Case of Multiple Myeloma(MM) with Myelofiblosis(MF) Undergone Autologous Peripherial Blood Stem Cell Transplantation.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 5496-5496
Author(s):  
Zhisheng Jiang ◽  
Shunjie Wu ◽  
Da Li ◽  
Qi Chen ◽  
Xinhao Lan ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Stem Cell ◽  
Bone Marrow Transplantation ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Plasma Cell ◽  
Marrow Transplantation ◽  
High Dose ◽  
Myeloid Metaplasia

Abstract Myelofibrosis with myeloid metaplasia(MMM) is a progenitor cell colony disease. The mechanism is not very clean. The prognosis is poor in MMM patients of the traditional treatment with Hydroxyurea, Interferne, Prednisone, transfusion. Thalidomide is a new anti-angiogenesis drug of inhibiting the genesis of fibrosis. Some reports presented that the cure method only is stem cell transplantation includes autologous and allogeneic bone marrow transplantation. Patient Sui, Man, 55 years, Chinese. He was hospitalized on Aug fifth, 2004, because he has had pale, severe weakness, for 5 months. T 36.C, HR 70, R 18/min, BP114/59 mmHg. Hb56g/L, WBC 5.7x109/L, Plt 72 x109/L.There were 0.66 plasma cell in bone marrow and his bone marrow aspiration with dry draw at the diagnosis,. The result of bone marrow biopsy was fibrosis. He received 4 courses of VAD regimens (VCR 0.4mg,d1–4; ADM 10mg,d1–4, DXM 40mg d1–4) before autologous peripheral stem cell (PBSCs) transplantation. The plasma cell count decreased from 0.66 before to 0.025 after the first course of VAD regimen in the bone marrow. The stem cell mobilization regimen was chemotherapy (cyclophosphamide, Cy, 2g/m2), high-dose methylprednisolone (MP), and G-CSF 250 ug, bid d1–5. The nucleated cell count of collection showed the a minimum of 4.17x108/kg per kg of body weight, CD34+ was 0.834x106/kg.The conditional regimen was melphalan 200mg/kg divided 2 times a day and cyclophosphamide 600mg VD. He received re-transfused PBSCs on March 25,2005. His neutrophil cell decreased 0 at +4 day after transplantation. He received platelet transfusion of single donor two times when his platelet decreased 7 x 109/L. his hemotopoietic recovered at +11d. He left transplantation ward +13 d. His platelet, WBC were normal, Hb 108g/L At+d. Bone marrow draw was no dry. There was 0.07 of plasma cell in his bone marrow. The result of reticulum protein stain was degree 3 after and 4 before PBSCT at +70d. Discussion: MM is incurable tumor because the tumor cells polluted in graft of bone marrow or peripheral blood stem cells. Some author considered the pollution tumor cell decreases with high-dose MP mobilization. Mobilization of stem cell in advanced MMM is difficulty, so we (1) increased the 3 times of mobilization, (2) added high-dose of MP to mobilization regimen of combination of Cy and G-CSF. The patient had received pre-transplantation of four courses of VAD chemotherapy regimen and the combination of west and Traditional Chinese Medicine to manage during stem cell transplantation. The patient had chronic gastric ulcer so we afraid of the condition result in relapse of it so we given the patient intravenous melphalan. Some researchers studied 21 cases of multiple myeloma were treated by autologous bone marrow transplantation. The condition regimen was melphalan 16 mg/kg. The role of allogeneic BMT as compared with autologous BMT is not yet defined. The patient had been followed up for 4 months, the result showed his plasma cell was 0.07 in his bone marrow. The degree of myeloid metaplasia had changed from degree 4 to 2. Conclusion: Intensive treatment with marrow rescue could induce complete remission of long duration in some patients and provided the basis for increased attempts to cure myeloma by intentive chemoradiotherapy and BMT. It is effective in multiple myeloma treatment with autologous stem cell transplantation. The curable method is only allogeneic stem cell maybe.

CD66 Expression on Malignant and Normal Plasma Cells: A Potential Target for Therapy.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 5073-5073 ◽  
Author(s):  
Deborah Richardson ◽  
Elizabeth Hodges ◽  
Adnan Mani ◽  
Kim Orchard
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Plasma Cells ◽  
Normal Individual ◽  
Conditioning Regimen ◽  
Becton Dickinson ◽  
Multiparametric Flow Cytometry ◽  
Plasma Cell Disorders ◽  
Dual Expression

Abstract CD66, a member of the carcinoembryonic antigen family, is known to be expressed on cells of myeloid and monocytic origin and has also been demonstrated on blasts from patients with B-lineage acute lymphoblastic leukaemia. An analysis of CD66 expression has been undertaken in bone marrow samples from patients with plasma cell disorders. Diagnostic bone marrow aspirate samples from 53 patients with multiple myeloma or monoclonal gammopathy were examined by multiparametric flow cytometry in order to demonstrate and quantitate plasma cells. Samples were analysed initially using a primary screening panel of antibodies including a combination of antiCD19 fluoroscein isothiocyanate (FITC)(Pharminogen), antiCD5 phycoerythrin (PE)(in-house), antiCD45 peridin chlorophyll protein (PerCP)(Becton Dickinson) and antiCD38 allophycocyanin (APC)(Phar). Samples shown to contain a CD45 negative, CD19 negative, CD38 positive population, consistent with the presence of plasma cells were then examined with a myeloma panel, including antiCD66. Samples from 41 patients were analysed using antiCD66 naked antibody (TheraPharm, GmBH) double-layered with sheep anti-mouse IgG F(ab’)2 fragment conjugated to FITC, antiCD138 PE, antiCD38 APC and antiCD45 PerCP. The correlation between CD38/CD138 and CD38/CD66 dual expression was 0.997. A further 13 samples were analysed using a commercial antiCD66 antibody conjugated to FITC (Dako). Again the correlation between CD38/CD138 and CD38/CD66 dual expression was 0.990. All patients apart from one, with morphologically detectable plasma cells, co-expressed CD66 with CD38. One patient with highly plasmablastic morphology did not express either CD38/138 or CD38/66 on plasma cells.The bone marrow of a normal individual was also examined and found to contain plasma cells which co-expressed CD19, CD138, CD38 and CD66. Plasma cells express CD66 in almost all patients with plasma cell disorders and expression has also been demonstrated on plasma cells in a normal individual. CD66 is therefore an attractive target for immunotherapy. A clinical trial using anti-CD66 targeted radiotherapy as part of the conditioning regimen for patients undergoing autologous or allogeneic stem cell transplantation, as therapy for multiple myeloma, is currently being conducted at our institution.

scholarly journals A Novel Case of Direct Antiglobulin Test-Negative Intravascular Hemolysis in a Patient with Smoldering Myeloma

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4539-4539
Author(s):  
Selina Dobing ◽  
Nikolas Desilet ◽  
Irwindeep Sandhu ◽  
Lauren Bolster
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
Plasma Cell ◽  
Light Chain ◽  
Plasma Cells ◽  
Case Reports ◽  
Alternative Pathway ◽  
Plasma Cell Dyscrasia ◽  
Intravascular Hemolysis ◽  
Lambda Light Chain

Abstract Objectives: 1. Describe a case of severe DAT-negative intravascular hemolysis in plasma cell dyscrasia. 2. Discuss a potential novel mechanism of light-chain mediated hemolysis. A 34-year old woman was admitted to hospital with fatigue and severe iron deficiency anemia (hemoglobin 47 g/dL, MCV 59 fL, ferritin 2 mcg/L). Her medical history included a presumptive diagnosis of paroxysmal nocturnal hemoglobinuria (PNH) from five years prior. She was transfused 2 units of red cells, started on oral iron and folate, and was discharged symptom-free with a hemoglobin of 71 g/dL. She returned three days later with abdominal pain, dark urine, and evidence of intravascular hemolysis. She was admitted for empiric treatment of PNH with high-dose glucocorticoids and therapeutic enoxaparin for presumed intra-abdominal thrombosis. Her flow cytometry, including granulocytes, was negative for PNH. Her direct antiglobulin test (DAT) was negative for IgG antibodies but positive for C3 complement. A thorough hemolysis workup was negative, including schistocytes and Donath Landsteiner testing. ADAMTS13 testing was uninterpretable due to high plasma free hemoglobin. Despite corticosteroids, brisk hemolysis continued with 10 units of RBCs required over 5 days to maintain a stable hemoglobin. Plasma free hemoglobin reached 1147 mg/L, prompting therapeutic plasmapheresis for renal protection by the end of day 5. She deteriorated clinically after her first plasmapheresis with acute confusion (GCS 10) and lactic acidosis. She was empirically treated for seizure with levetiracetam. CT and MRI scans of her brain and lumbar puncture were normal. Her consciousness improved with daily plasmapheresis. A bone marrow biopsy performed on day twelve of glucocorticoid therapy found monoclonal plasma cell proliferation of 15% with marked lambda light chain predominance (20:1) (Figure 1). Repeat bone marrow biopsy 3 months post-steroid therapy still revealed 10% clonal plasma cells. Hemolysis can be a rare presentation of plasma cell dyscrasia. Case reports of both autoimmune hemolytic anemia and microangiopathic hemolytic anemia associated with multiple myeloma exist. In our case, there was no evidence of a microangiopathic process, making thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic-uremic syndrome (aHUS) unlikely. DAT was negative for IgG but did demonstrate C3 complement molecules bound to red cells. No previous case reports of complement-mediated hemolysis and multiple myeloma were found on literature review. We report the first in vivo association between complement-mediated hemolysis and plasma cell dyscrasia. Complement pathways bridge the innate and acquired immune systems by helping select cells to be targeted by the acquired immune system. The alternative complement pathway does not require an antigen-antibody interaction to become active; rather, it is controlled by direct binding of complement and regulated by cofactor molecules. Jokiranta et al. (J Immunol 1999) identified a monoclonal Ig-lambda dimer that efficiently activated the alternative pathway of complement, triggering complement molecules to enhance hemolysis of serum in vitro. This "miniautoantibody" specifically bound and blocked the function of complement factor H, inhibiting enzymatic inactivation of fluid-phase C3b with uncontrolled activation of the alternative pathway. It is possible that the relative immune dysfunction in this patient's plasma cell dyscrasia led to a disturbance in the alternate complement pathway, perhaps due to dimerization of abnormal lambda light chains, resulting in complement-mediated intravascular hemolysis. Glucocorticoids and plasmapheresis may have helped manage hemolysis in this case. By diagnostic criteria, this patient has smoldering myeloma, with urine monoclonal protein (1.2 g/24 hours), clonal bone marrow plasma cells (10-15%), and absence of myeloma-defining events. We have elected to manage her as such, with close observation. Further work-up performed for her plasma cell dyscrasia included a normal MRI of spine and pelvis. Over a year later, there has been no recurrence of hemolysis. Consideration will be given to treatment if she progresses to overt multiple myeloma. Figure 1. A. Aspirate showing abnormal plasma cells. B. Trephine CD138 stain. C. Trephine kappa light chain stain. D. Trephine lambda light chain stain. Figure 1. A. Aspirate showing abnormal plasma cells. B. Trephine CD138 stain. C. Trephine kappa light chain stain. D. Trephine lambda light chain stain. Disclosures Sandhu: Novartis: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria; Janssen: Consultancy, Honoraria.

scholarly journals Novel Alkylating Agent Melflufen Displays Potent Efficacy in Plasma Cell Leukemia Samples and Other High-Risk Subtypes of Multiple Myeloma

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 12-13
Author(s):  
Beau M Idler ◽  
Olivia Perez De Acha ◽  
Owen Lockerbie ◽  
Ken Flanagan ◽  
Fredrik Lehmann ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Bone Marrow ◽  
High Risk ◽  
Plasma Cell ◽  
Research Funding ◽  
Ex Vivo ◽  
Plasma Cell Leukemia ◽  
Peptide Drug ◽  
Cell Leukemia ◽  
Plasma Cell Disorders

Introduction: Despite the progress that has been made for standard risk multiple myeloma (MM), subsets of patients with the most advanced and aggressive plasma cell dyscrasias still suffer comparatively poor outcomes. One example is plasma cell leukemia (PCL), which carries a median overall survival of under two years. For patients with PCL, response to front line therapy occurs but is often short-lived, ultimately giving way to aggressive multi-drug resistant disease and patient mortality. Thus, there is a need for the development of new strategies that improve the prognoses for these patients. Melflufen (melphalan flufenamide) is a first-in-class peptide-drug conjugate that is currently in late-phase clinical trials for multiple myeloma. This highly lipophilic agent is preferentially retained in malignant plasma cells (MPCs), where overexpressed aminopeptidases lead to trapping of the alkylator melphalan. We evaluated the anti-myeloma effects of melflufen on patient samples treated ex vivo, and found pronounced sensitivity to melflufen in most samples, with particularly potent efficacy in PCL samples. Methods: Bone marrow aspirate or peripheral blood samples were obtained from patients with plasma cell disorders after IRB approval and informed consent. Ex vivo efficacy of melflufen and melphalan were compared using our Myeloma Drug Sensitivity Testing (My-DST) platform that optimizes viability and tests the malignant cells in the context of the normal cells from their microenvironment (Walker et al, Blood Advances, 2020). In brief, mononuclear cells from patients with plasma cell dyscrasia, including MM and PCL, were isolated and cultured in triplicate wells with titrations of melphalan, melflufen or untreated controls for 48 hours. Post-treatment survival was measured by high-throughput flow cytometry with antibodies for CD138, CD38, CD45 and CD19, and a live/dead dye to discriminate viable MPCs from normal bone marrow cells. EC50 values were determined from these titrations using nonlinear regression curve fits. When the EC50 for melflufen was established in My-DST, a single dose concentration of 10 nM was used to screen patient samples and distinguish relative sensitivity or resistance. Results: Using the My-DST approach with 48 hour drug treatments, melflufen significantly decreased the viable MPC populations, whereas melphalan had little effect (Fig 1A). Concurrent titrations revealed significantly higher MPC sensitivity to melfufen (mean melphalan EC50 = not reached, mean melflufen EC50 = 22.9 nM) (Fig 1B). By comparison to another alkylator, cyclophosphamide's active metabolite has an EC50 of 3.75 µM in this assay. Response to melflufen was accentuated in 2/3 PCL samples tested (HTB-1802.1, HTB-1389.1), with the EC50 &lt; 1nM (Fig 1B). Melflufen demonstrated toxicity in CD45 positive white blood cells, which is consistent with neutropenia observed in clinical trials (data not shown). In single dose screening studies in additional MM patient samples, 4/8 (50%) showed &gt;20% decrease in viable MPCs after incubation with melflufen at 10 nM (Fig 1C). Overall, using those parameters for ex vivo "response" to meflufen, 3/3 patients with PCL responded, 5/6 patients with del(17p) responded, and 3/3 patients with c-MYC translocations responded (Fig 1C, italics). In addition, 3/5 samples from patients that were clinically daratumumab-refractory displayed sensitivity to melflufen. Of five samples from patients with prior exposure to alkylators, four were sensitive to melflufen. Conclusion: Overall, these data support that the peptide-drug-conjugate melflufen shows a broad efficacy across samples from patients with plasma cell disorders. Patients facing poor prognoses, including those with PCL, high-risk cytogenetics and daratumumab-refractory disease, have a great need for new treatments. Thus, the encouraging ex vivo results with melflufen in samples from these aggressive subsets support further clinical exploration. In particular, our preliminary data suggest that plasma cell leukemia patients may be exquisitely sensitive to melflufen. To follow-up these findings, we will expand the number of samples tested from PCL and other forms of high-risk MM samples. Ultimately, if the trend for accentuated sensitivity in plasma cell leukemia holds, a clinical approach for melflufen in these patients may improve outcomes for this group. Figure 1 Disclosures Lockerbie: Oncopeptides AB: Current Employment. Flanagan:Oncopeptides AB: Current Employment. Lehmann:Oncopeptides AB: Current Employment. Forsberg:Celgene: Speakers Bureau; Genentech, Inc., Sanofi, Karyopharm, Abbvie: Research Funding. Mark:Takeda: Consultancy; Kayopharm: Consultancy; Bristol-Myers Squibb: Research Funding; Janssen: Research Funding; Celgene: Consultancy; Amgen: Consultancy; Sanofi: Consultancy; Janssen: Consultancy. Sherbenou:Oncopeptides Inc.: Research Funding.

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