Unmeasurable Serum M-Protein Multiple Myeloma Benefit Less from Bortezomib Than Measurable Myeloma

Abstract Background: According to international uniform response criteria for multiple myeloma(MM), unmeasurable disease is defined as serum M-protein level of less than 1 g/dl and urine M-protein level less than 200 mg/d. The anti-tumor activity of bortezomib partly depended on degradation of misfolded or unfolded proteins through ubiquitin-proteasome pathway. We postulate that bortezomib may not able to induce sufficient apoptosis in unmeasurable serum M-protein myeloma comparing with measurable group. The goal of this study is to determine whether the level of serumM-protein expression act as a validated surrogate marker to predict the prognosis in the bortezomib-based therapy. Materials and Methods: Between 2004 and 2013, a retrospective study was carried out of 630 patients with new diagnosis MM (NDMM) excluding light chain MM, who underwent bortezomib-based therapy or thalidomide-based therapy and for whom had complete data on clinical characteristics, molecular cytogenetics variety, treatment and overall survival (OS) time. According to the level of M-protein, they were devided into two groups: unmeasurable (serum M-protein<1g/dl) and measurable (serum M-protein>1g/dl) M-protein MM. Results: 1) 92 patients were defined asunmeasurable M-protein MM and were 14.60% of the 630 cases cohort. 2) Compared with measurable M-protein MM, unmeasurable M-protein MM were characterized by younger age(54.89 vs.58.85, p<0.001), lower frequency of IgG and IgA M-protein type (IgG, 14.13% vs. 68.96%; IgA, 21.74% vs. 30.86%; p<0.001), higher incidence of IgD M-protein type (IgD, 36.96% vs. 0.19%; p<0.001), lower frequency of kappa light chain involved (kappa, 26.09% vs. 53.72% p<0.001), higher level of albumin (44.44 vs.32.34, p<0.001) and higher median of LDH (265.29 vs.168.99, p<0.001), higher incidence of renal dysfunction (33.70% vs 16.54%, p<0.001 ) and less advanced ISS stage (Ⅰ, 34.09% vs. 17.30%; Ⅱ, 21.69% vs. 42.54%; Ⅲ, 44.32% vs.40.16%; p<0.001). In addition, unmeasurable M-protein patients had higher incidence of del(17p) ( 15.49% vs. 5.45%; p=0.001) and t(11;14) ( 35.85% vs. 13.99%; p<0.001). However, the incidence of del(13q), 1q21 gains and t(4;14), t(14;16) had no statistically significance (p>0.05). 3) Furthermore, we analyzed OS in these two groups with thalidomide-based or bortezomib-based chemotherapy. In thalidomide-based therapy, the median OS of unmeasurable and measurable M-protein MM were 32.0 (95% CI: 14.3-49.7) and 40.0 (95% CI: 34.3-45.7) months respectively (p=0.124).In bortezomib-based group, the median OS of unmeasurable and measurable M-protein MM were 29.5 (95% CI: 15.4-43.6) and 58.0 (95% CI: 46.1-70.0) months respectively. The unmeasurable M-protein MM had a remarkably shorter OS (P=0.034). Secondly, patients were stratified according to level of M-protein (unmeasurable and measurable), then compared according to treatment. In unmeasurable M-protein MM, the median OS of bortezomib group and thalidomide groupwere 29.5 (95% CI: 15.4-43.6) and 32.0 (95% CI: 14.3-49.7) months respectively(p=0.498). In measurable M-protein MM with bortezomib and thalidomide-based chemotherapy, the median OS were 58.0 (95% CI: 46.1-70.0) and 40.0 (95% CI: 34.3-45.7) months respectively (p=0.004). Conclusion: In conclusion, unmeasurable serum M-protein myeloma had shorter OS than measurable group, especially in the bortezomib-based therapy. In unmeasurable group, the difference of OS was not significant between thalidomide-based and bortezomib-based therapy. Our findings suggested that the level of serum M-protein was capable of predicting different survival groups to bortezomib and unmeasurable myeloma might benefit less than measurable group from bortezomib. Disclosures No relevant conflicts of interest to declare.

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Smoldering Multiple Myeloma: Usefulness of Serum Heavy/Light Chain Measurements for the Evaluation of Evolving Pattern

Blood ◽

10.1182/blood-2018-99-117385 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 4514-4514

Author(s):

Carlos Fernandez de Larrea ◽

Ignacio Isola ◽

Esther Moga ◽

Maria Teresa Cibeira ◽

Ester Lozano ◽

...

Keyword(s):

Risk Factors ◽

Multiple Myeloma ◽

Prognostic Factors ◽

Light Chain ◽

Protein Level ◽

Progressive Increase ◽

M Protein ◽

Smoldering Multiple Myeloma ◽

Risk Of Progression

Abstract Introduction: Smoldering multiple myeloma (SMM) is an asymptomatic and biologically heterogeneous clonal plasma cell disorder. A number of prognostic factors to identify patients at a higher risk of progression have been described, such as the size of the M protein, proportion of abnormal bone marrow plasma cells (BMPCs), immunoparesis and serum free light chain (FLC) k/l ratio. More recently, isotype-specific uninvolved heavy and light chain (HLC) pair suppression measured with the Hevylite assay was also associated with an increased risk of progression. Recent studies have evaluated the key prognostic impact of an increase in M-protein levels during follow-up ("evolving" pattern). However, an important limitation could be the evaluation of M-protein level variations based on serum protein electrophoresis (SPE) in patients with a small size M-spike. The aim of this study was to prospectively analyze the changes in M-protein according to SPE and HLC measurements, as well as other risk factors for progression, in patients with SMM. Methods: Thirty patients newly diagnosed with SMM at a single institution from January 2014 through September 2017 were prospectively included in the study. For each patient, baseline levels of known prognostic factors (serum M-protein, serum and urine immunofixation, clonal BMPCs percentage, total immunoglobulins, involved/uninvolved FLC and involved/uninvolved HLC pairs) were recorded. During the follow up, M-protein level, FLC and isotype specific HLC pairs were also analyzed. Evolving change in M-protein level according to SPE was defined as ³ 10% increase within the first 6 months of diagnosis (if M-protein was ³ 30 g/L) and/or ³ 25% increase within the first 12 months (for any level of M-protein); evolving change according to HLC was defined as a ³ 10% increase in the involved pair. A sequential increase in each of three or more consecutive measurements from diagnosis was considered an evolving change regardless of its magnitude. Results: The clinical characteristics of the total of patients, as well as of the patients with evolving changes in M-protein according to HLC are summarized in Table 1. During the study period, 5/30 (17%) of patients demonstrated an evolving behavior of the M-protein according to SPE. Four of these patients (4/5) also showed a progressive increase in the M-protein in the HLC measurements. One patient showed stable HLC levels even though both the M-protein and the involved FLC progressively increased. This patient was of intermediate and low risk according to Mayo Clinic and PETHEMA scores, respectively. On follow up, no progressive suppression of the isotype-specific uninvolved HLC pair or increase in the FLC ratio was noted, and there have been no signs of progression after a follow up of 3 years. According to involved HLC-pair levels, 12/30 (40%) of patients demonstrated an evolving behavior. Five out of 7 patients that were not classified as evolving by SPE, were IgA isotype. Eight out of 12 patients showed severe isotype-specific suppression of the uninvolved HLC-pair (> 50% below lower level of normal) as well as a highly abnormal FLC ratio (<0.125 or >8). Three out of the 4 remaining patients showed either severe isotype-specific HLC pair suppression or highly abnormal FLC ratio in follow up measurements. Compared to patients with no "HLC-evolving pattern", evolving patients were more likely to have highly abnormal FLC ratios (90 vs. 33%, p=0.009), severe suppression of the other isotypes (64 vs. 19%, p=0,024), highly abnormal isotype-specific HLC ratios (67 vs. 33%, p=NS), severe isotype-specific HLC-pair suppression (75 vs. 50%, p=NS), and immunoparesis (67 vs. 39%p=NS). Five patients progressed to symptomatic multiple myeloma during follow up; 4 of them showed a progressive increase in the involved HLC pair from diagnosis. The remaining patient demonstrated a progressive increase in the involved HLC pair that started 19 months prior to progression, followed 4 months later with an increase in M-protein as measured by SPE. Conclusions: In our series, the Hevylite assay allowed us to identify patients with a progressive increase in M-protein (clonal heavy/light chain pair) that was not evident with SPE measurements. This "HLC evolving pattern" was associated with other risk factors for progression to symptomatic disease and with worsening of other prognostic parameters during follow up. Disclosures Rosinol: Janssen, Celgene, Amgen, Takeda: Honoraria. Bladé:Janssen: Honoraria.

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Prevalence of Monoclonal Gammopathy of Undetermined Significance in a Large Population with Annual Physical Examination in Beijing, China

Blood ◽

10.1182/blood-2019-124715 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 5519-5519

Author(s):

Jinuo Wang ◽

Jian-Hua Han ◽

Yue-lun Zhang ◽

Xin-xin Cao ◽

Dao-Bin Zhou ◽

...

Keyword(s):

Physical Examination ◽

Light Chain ◽

Chinese Population ◽

Monoclonal Gammopathy ◽

Conflicts Of Interest ◽

Large Population ◽

M Protein ◽

Monoclonal Protein ◽

Significant Difference ◽

Undetermined Significance

Introduction Monoclonal gammopathy of undetermined significance (MGUS) is a clinically asymptomatic premalignant plasma cell disorder. Previous studies in Western countries have described the prevalence of MGUS in Caucasians. However, data is limited in Chinese population. We therefore performed this study to ascertain the prevalence and characteristics of MGUS among Chinese population. Methods A total of 154597 consecutive healthy participants from Beijing who underwent annual physical examination between December 2013 and April 2019 at Peking Union Medical College Hospital were enrolled. Serum M protein was evaluated by capillary electrophoresis. Patients with a positive or suspicious serum M protein were suggested to be referred to the hematological clinic for immunofixation electrophoresis (IFE) and free light chain (FLC) assays. MGUS was defined in accordance with previous definitions. We calculated age-specific and sex-specific prevalence and described laboratory characteristics of patients with MGUS among those participants. Results MGUS were diagnosed in 843 patients (0.55%, 95%CI 0.51% to 0.59%). The median age at presentation was 58 years, with a range of 25-96 years. The overall prevalence of MGUS was 1.14% among participants aged 50 years or older and 2.6% among those aged 70 years or older. In both sexes, the prevalence increased with age: 0.1% (<40 years), 0.36% (40-49 years), 0.78% (50-59 years), 1.28% (60-69 years), 2.19% (70-79 years), and 3.77% (≥80 years) separately (Figure 1). The prevalence among men were higher than that among women (0.67% vs. 0.40%, OR =1.719, 95% CI 1.490 to 1.983, P<0.001) (Figure 1). The median concentration of serum Monoclonal protein was 1.4 g/L (0.1 -27.8 g/L). M protein level was less than 0.5g/L in 220 patients (26.1%), less than 5 g/L in 81.1% and more than 15 g/L in only 1.9% of 843 persons. There was no significant difference in the concentration of the monoclonal protein among the age groups. Of the 519 patients who were tested for IFE, the isotype of the monoclonal immunoglobulin was IgG in 344 (66.3%), IgA 112 (21.6%), IgM in 48 (9.2%), IgD in 2 (0.4%), light-chain in 3 (0.6%) and biclonal in 10 (1.9%). The serum light-chain type was kappa in 260 (50.1%), lambda in 255 (49.1%) patients, while 4 patients (0.8%) with biclonal M protein have both kappa and lambda light-chain. Of the 180 people who were tested for FLC, 42 (23.3%) had an abnormal FLC ratio. IgG isotype, M protein <15 g/L and normal FLC ratio were found in 102 patients (56.7%) and the remaining 78 people (43.4%) had 1(30.6%) or 2(12.8%) abnormal factors. Conclusions MGUS was found in 1.14% of persons 50 years of age or older and 2.6% among those 70 years of age or older among healthy Chinese population. The prevalence of MGUS increases with age. Males have a higher frequency of MGUS than Females. These observations offer the overall situation of MGUS epidemiology in a large Chinese population. Disclosures No relevant conflicts of interest to declare.

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Raised ?2-Microglobulin as a Surrogate Marker in Non-Secretory Multiple Myeloma

Bangladesh Journal of Medical Science ◽

10.3329/bjms.v16i1.31146 ◽

2017 ◽

Vol 16 (1) ◽

pp. 142-145

Author(s):

Bimal K Agrawal ◽

Anshul Sehgal ◽

Vikas Deswal ◽

Prem Singh ◽

Usha Agrawal

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

Rare Case ◽

Plasma Cells ◽

Medical Science ◽

Protein A ◽

Surrogate Marker ◽

M Protein ◽

Review Of Literature ◽

Lytic Lesions

Multiple myeloma is a neoplasm of plasma cells in the bone marrow. It is characterised by lytic lesions in the bones, marrow plasmacytosis and presence of M protein in serum and/or urine. Serum ?2 microglobulin is also raised and can be used for classification and prognostication of the disease. In the absence of M protein, the disease is known as non-secretory myeloma. It is proposed that raised ?2 microglobulin can be used for diagnosis and therapeutic guidance in the absence of M protein. A rare case of nonsecretory myeloma with neurocognitive impairment along with review of literature is being presented. The patient had multiple lytic lesions in bones with marked increase in plasma cells in bone marrow. M protein was not detectable in serum or urine but serum ?2 microglobulin was much elevated.Bangladesh Journal of Medical Science Vol.16(1) 2017 p.142-145

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Lovastatin as Salvage Immunomodulatory Therapy in Patients with Refractory and Relapsed Multipla Myeloma.

Blood ◽

10.1182/blood.v106.11.1567.1567 ◽

2005 ◽

Vol 106 (11) ◽

pp. 1567-1567 ◽

Cited By ~ 1

Author(s):

Marek Hus ◽

Norbert Grzasko ◽

Dariusz Jawniak ◽

Marta Szostek ◽

Anna Dmoszynska

Keyword(s):

Stem Cells ◽

Bone Marrow ◽

Light Chain ◽

Protein Level ◽

Mevalonate Pathway ◽

Sinus Bradycardia ◽

Autologous Transplantation ◽

M Protein ◽

Hmg Coa Reductase ◽

Coa Reductase

Abstract In the recent years the treatment of patients with multiple myeloma (MM) has changed because of the introduction of new agents, mainly thalidomide (THAL) and its derivatives and bortezomib, an inhibitor of the 20S proteasome. Lovastatin (LOV) and other inhibitors of HMG-CoA reductase, the rate-limiting enzyme of the mevalonate pathway, have been demonstrated to exibit antineoplasmatic and proapoptotic properties in numerous in vitro studies involving myeloma cell lines including our own experiments. This observation induced us to administer LOV in combination with THAL and dexamethasone (DEX). We report here our preliminary experiences with THAL and LOV therapy in patients with refractory and relapsed MM. We have treated 81 patients with THAL+DEX regimen (TD) or THAL+DEX+LOV regimen (TLD). Patients received drugs orally in 28 day cycles. THAL was given from day 1 to day 28 each cycle and it was started at a initial dose of 100 mg daily increased to 300 mg daily. DEX was administered at a dose of 40 mg daily in days 1–4 each cycle. LOV was administered at a dose of 2 mg/kg in days 1–5 and 8–12 and at a dose of 0.5 mg/kg in days 15–28 each cycle. TLD regimen was administered to 43 patients and TD regimen to 38 patients. Patients characteristics before treatment were as follows: the median age 61.2 years; 61% of patients IgG, 26% IgA, 7% light chain and 6% other; 76% of patients were light chain kappa and 24% lambda; median serum M-protein level was 4.2 g/dl, bone marrow plasma cells 47%, hemoglobin 10.1 g/dl, platelets 197 G/l, beta-2-microglobulin 4.2 mg/ml, albumin 3.9 g/dl and LDH 292 IU. The median follow-up was 29 month. A clinical response, defined as a reduction of M-protein level by 50% or more, was observed in 67.8% of patients in TD group and in 88.0% in TLD group. CR i NCR was observed in 35.0% and 62.7% respectively. In 11 TLD (25.5%.) and 4 TD (10.5%) patients successful stem cell harvest was performed and mean amount of collected CD34+ cells was 8.2*106/kg. Successful autologous transplantation was performed in 8 patients from this group. Overall survival in TLD group (median 23.0 months) was significantly longer than in TD group (median 18.0 months). Similarly event free survival was longer in TLD (median 7.0 months) group than in TD group (4.5 months). We observed significant negative correlation between response and bone marrow infiltration (p=0.008), M-protein level (p=0.0004) and positive correlation between response and albumin level (p=0.005). Short time to reduction of M-protein by 50% was connected with better response. Common side effects as somnolence, fatigue and constipation were observed in about 45% of patients in TLD and TD groups. In 2 TLD and in 3 TD patients we diagnosed deep vein thrombosis. In 2 TLD patients sinus bradycardia was observed. Our results suggest that addition of LOV to THAL and DEX improves response rate in patients with refactory and relapsed MM. Moreover it is possible to harvest stem cells and perform autologous stem cells graft in patients treated with such regimen. A future prospective randomised study is needed to confirm the value of LOV or other HMG-CoA reductase inhibitors in the treatment of MM patients.

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Comparison of Serum Free Light Chain Levels and 24 Hour Urinary Monoclonal Protein Secretion in Patients with Myeloma: Concordant Changes with Response to Therapy.

Blood ◽

10.1182/blood.v108.11.5064.5064 ◽

2006 ◽

Vol 108 (11) ◽

pp. 5064-5064 ◽

Cited By ~ 1

Author(s):

Shaji Kumar ◽

S. Vincent Rajkumar ◽

Matthew Plevak ◽

Robert A. Kyle ◽

Jerry A. Katzmann ◽

...

Keyword(s):

Light Chain ◽

Protein Level ◽

Free Light Chain ◽

Response To Therapy ◽

M Protein ◽

Serum Free ◽

Protein Levels ◽

Serum Free Light Chain ◽

Data Points ◽

Over Time

Abstract Background: The measurement of monoclonal (M) protein in the serum and urine is critical for response assessment and disease evaluation in patients with multiple myeloma (MM). The serum free light chain (FLC) assay offers a new and sensitive method of assessing response to therapy. An important question that has not been adequately addressed is the correlation between 24 hour urine M protein levels and serum FLC measurements, and the extent to which response to therapy estimated using the FLC assay correlates with that assessed using the 24 hour urine M protein level. Methods: A total of 2194 sets of data, with simultaneous UPEP and serum FLC measurement, were studied. These included 752 unique patients, with individual patients having 1–23 paired assessments over time. FLC estimation was carried out using the serum FLC assay (Freelite; The Binding Site Limited, UK) performed on a Dade-Behring Nephelometer. Based on the established reference range, kappa/lambda FLC ratio <0.26 or >1.65 were defined as abnormal indicating the presence of monoclonal lambda and kappa FLC, respectively. The monoclonal light chain isotype was considered the involved FLC isotype, and the opposite light chain type as the uninvolved FLC type. The Urine M protein by UPEP was compared to the serum levels of the involved light chain using Spearman Rank Correlation. For comparisons in individual patients over time, those with at least 10 measurements each were studied. Results: The median involved FLC level in patients with an undetectable urine M protein was 2.3 mg/dl compared to 32.2 mg/dL among those with a detectable urine M protein (P<0.001). Among the 1676 points with an abnormal FLC ratio, only 75% had an M protein detected in the urine, P < 0.001. Conversely, among patients with a positive urine M-protein, 91% had an abnormal FLC ratio. When all the 2194 data points were considered together, there was a significant correlation between the urine M protein level and the FLC levels (FLC level calculated as the difference between involved and uninvolved levels), rho=0.763, P < 0.001. The correlation did not change when patients with a serum creatinine of over 2.5 were excluded. The correlation between FLC levels and urinary M protein can be affected by several factors such as renal function that will differ across patients. Therefore, we examined whether the correlation between the two variables is stronger when the variations introduced by inter-patient differences in the relationship between the two variables are eliminated. In order to do this, we studied individual patients on whom multiple data points over time were available. One patient who had the maximum number of paired assessments (23 pairs) of serum FLC level and urinary M protein; the correlation between the two variables over time was highly significant, rho 0.981, p<0.001. Similarly 26 other patients who had measurable urine M protein levels in whom 10 nor more paired observations over time were available, also showed significant correlations, rho, range 0.726–0.981, p<0.01. Conclusion: There is a significant correlation between urine M-protein and serum free light chain across patients and the correlation is stronger in individual patients in whom the effect of inter-patient variation in other confounding factors can be eliminated. These data if confirmed in a clinical trial setting would support the use of serum FLC levels instead of urinary M protein measurements to assess response to therapy.

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Improving Outcomes in Patients with Renal Failure Secondary to Multiple Myeloma: Results From ChAR2M2.

Blood ◽

10.1182/blood.v114.22.1875.1875 ◽

2009 ◽

Vol 114 (22) ◽

pp. 1875-1875

Author(s):

Colin Hutchison ◽

Parisa Airia ◽

Mark Cook ◽

Daniel Grima

Keyword(s):

Multiple Myeloma ◽

Renal Failure ◽

Side Effects ◽

Light Chain ◽

De Novo ◽

Conflicts Of Interest ◽

Treatment Patterns ◽

Free Light Chain ◽

High Rate ◽

Sustained Reduction

Abstract Abstract 1875 Poster Board I-900 Study purpose: To explore how free light chain (FLC) removal by high cut-off haemodialysis (HCO-HD) has been adopted into clinical practice for the management of renal failure secondary to multiple myeloma. Describing treatment patterns and the laboratory and clinical outcomes associated with its use. Methods: A chart audit of patients treated with FLC removal by HCO-HD, using the Gambro HCO 1100 dialyser, was performed in 16 dialysis centers across 9 countries. Patient demographics, treatment patterns and dialysis side-effects were recorded. In addition, the following outcomes were measured: dialysis independence and reductions in serum FLCs concentrations at 12 and 21 days. Results: Data for 66 patients was entered. Patients had an average age of 65.1 (SD×10.1); 42 of them (63.64%) were male and 24 (36.36%) were female. Sixteen (24%) presented with relapsing myeloma and 50 (76%) had de novo disease. On average, each patient received 13 HCO-HD sessions (SD×8). Forty-one patients became dialysis independent (62.12%), after an average of 12 sessions. Dialysis related side-effects were reported in 6% of all patients. Forty patients (60.61%) were reported to have a sustained reduction in serum FLC concentrations by day 12. By day 21 this had increased to forty-one (62.12%). Among the patients who achieved a sustained reduction in serum FLC concentrations, 28 (70%) had a decline in FLC levels of more than 50% by day 12 and 34 (82.93%) by day 21. Among patients who achieved sustained reduction of more than 50% in serum FLC concentrations by day 12, 75% became dialysis independent. In comparison only 53% of those with a reduction of less than 50% became dialysis independent (p×0.007). Furthermore, among patients who achieved sustained FLC reduction of greater than 75%, 81% became dialysis independent. The rate of dialysis independence was also significantly higher in patients with de novo disease compared with those with relapsing myeloma (64% versus 56%, p×0.04). Conclusion: Free light chain removal by HCO-HD was well tolerated and associated with a very high rate of dialysis independence in patients with renal failure secondary to multiple myeloma. Rates of renal recovery were greater in patients with de novo myeloma and those who achieved an early reduction in serum FLC concentrations. Disclosures: No relevant conflicts of interest to declare.

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Efficacy of Lenalidomide-Based Regimens in Multiple Myeloma Complicated by Extramedullary Plasmacytomas at Relapse or Progression.

Blood ◽

10.1182/blood.v114.22.4952.4952 ◽

2009 ◽

Vol 114 (22) ◽

pp. 4952-4952 ◽

Cited By ~ 1

Author(s):

Jose Manuel Calvo-Villas ◽

Adrian Alegre ◽

Ricarda García-Sánchez ◽

Miguel T Hernández ◽

Pilar Giraldo ◽

...

Keyword(s):

Multiple Myeloma ◽

Median Time ◽

Light Chain ◽

Conflicts Of Interest ◽

Bone Lesions ◽

Complete Disappearance ◽

Toxicity Profile ◽

Small Series ◽

Extramedullary Plasmacytomas

Abstract Abstract 4952 Background Current clinical observations on extramedullary myeloma (EM) are based on small series of relapsed myeloma patients (pts) and, in this situation, results suggest that the disease course is often aggressive. Among novel therapies for extramedullary involvement, thalidomide has provided poor results and bortezomib is emerging as a possible useful drug. The role of lenalidomide for treatment of multiple myeloma (MM) with EM is still under investigation. Aim A multicenter retrospective study was performed by PETHEMA (Spanish Myeloma Group, Spain) to evaluate the response rate and toxicity profile of lenalidomide-based regimens in myeloma patients with extramedullary involvement at relapse or progression. All the cases were evaluated for response of MM and improvement of extramedullary plasmacytoma. Patients and Methods From October 2007 to March 2009, thirteen patients (median age 67 years; range 61–87; 7 females) treated with lenalidomide-containing regimens were recorded. Patients with bone disease without extramedullary manifestations were excluded. Response of MM was evaluated according to the new international criteria and the response of EM by measuring size changes by physical examination, CT scans and/or MR imaging. Adverse events were graded based on the WHO toxicity scale. The M-protein type was IgG in 7 cases, IgA in 5 and light chain in 1. The type of light chain was κ in 7 pts and l in 6. In eight patients the soft-tissue plasmacytomas may have developed from underlying bone lesions [(skull (n=2), rib cage (n=4) and paravertebral (n=2)], two patients had subcutaneous nodules and three had visceral involvement (liver (n=1), lung and kidney (n=1) and pleura (n=1). Multiple localizations were present in 4 pts (30.7%). Six cases (79.6%) received previous antimyeloma treatment for EM before lenalidomide therapy and the incidence of prior bone plasmacytomas was 61.5%. Median time from initial antimyeloma therapy to treatment with lenalidomide was 34 months (range 5 - 115). Median number of prior lines of chemotherapy regimens was 3 (range 1 – 4), including autologous stem cell transplantation in 2 pts, bortezomib-containing regimens in 12 (92.3%) and previous exposure to thalidomide in 1 patient. Ten pts received standard lenalidomide dose (25 mg/day every 4 weeks) plus dexamethasone (40 mg/d PO ranging from 1 to 12 doses/cycle) every 3-week; and three patients received lower doses of lenalidomide and/or different schedules. Involved-field radiotherapy was given in 2 cases. Thirty percent of patients required lenalidomide dose reduction, because of toxicity or intolerance. Results Median duration of lenalidomide treatment was 3.6 months (1 – 15). One case was not evaluable for response because of death from disease progression after one cycle. In nine out of twelve evaluable patients (75%), MM responded to lenalidomide regimens according to EBMT criteria. Three (25%) achieved complete response, five (41.6%) partial response and 1 (8.3%) minimal response. Median time to response was 63 days (range 37 – 180). Regarding EM, nine patients showed response in the size of extramedullary plasmacytomas. Seven (58.3%) achieved complete disappearance of EM and two pts reduction of the size. Response of EM was also achieved in 75% of pts previously exposed to bortezomib, and in 4/9 cases who received therapies for prior extramedullary involvement. Median follow-up period was 6.3 months (1 – 15.8). Median overall survival from the start of lenalidomide therapy was 4.7 months. At the time of analysis, seven patients were still on therapy, and ten (76.9%) were alive. Only one out of the 9 patients who had achieved a response has relapsed so far. Toxicity profile (grade 3/4) was: thrombocytopenia, 4 (30.7%); anemia, 2 (15.3%); neutropenia, 5 (46.4%); neutropenic fever, 1 (7.6%) and others, 3 (11.8%). No deep venous thrombosis (DVT) was reported. Thrombosis prophylaxis was used in most cases (92%) patients. Conclusions We report one of the first investigations specifically evaluating the activity of lenalidomide on EM. Lenalidomide-containing regimens could be an alternative promising approach to achieve clinical response in heavily treated MM patients with extramedullary disease. The duration of response and the best regimen or combination are at present unknown. These preliminary observations require further analysis and longer follow-up. Disclosures No relevant conflicts of interest to declare.

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High Frequency of Monoclonal Immunoglobulins Exhibiting Natural Autoantibody-Like Activity in Patients with Multiple Myeloma and Waldenström Macroglobulinemia

Blood ◽

10.1182/blood.v118.21.2893.2893 ◽

2011 ◽

Vol 118 (21) ◽

pp. 2893-2893

Author(s):

Peggy Lymberi ◽

Evangelos Terpos ◽

Aikaterini Hatzioannou ◽

Evangelos Eleutherakis-Papaiakovou ◽

Apostolos Balafas ◽

...

Keyword(s):

Multiple Myeloma ◽

Carbonic Anhydrase ◽

Light Chain ◽

Conflicts Of Interest ◽

Significant Proportion ◽

Similar Proportion ◽

Antibody Activity ◽

Monoclonal Gammopathies ◽

High Incidence ◽

Monoclonal Immunoglobulins

Abstract Abstract 2893 Serum monoclonal immunoglobulins (M-Igs) of patients with monoclonal gammopathies are known to possess antibody activity against autoantigens, bacterial antigens and haptens, but their incidence is controversial. So far, high incidence of autoantibodies (autoAb) have been demonstrated against actin, Ro/SS-A and La/SS-B for M-Igs of all three classes (IgG, IgA, IgM) and against Fc fragment of IgG and the Ii group exclusively for IgM M-Ig. Other less frequent antiboby specificities of M-Igs include anti-myosin, anti-tubulin, anti-thyroglobulin and anti-DNA. M-Igs with anti-actin activity were found to express polyreactivity, which is a property of natural autoAbs (NAbs). NAbs are germ-line encoded, occur in all species, circulate in low concentrations and belong to all Ig classes. NAbs play important immunoregulatory role and anti-F(ab')2 reactivity is crucial for the establishment of the idiotypic network. The aim of this study was to investigate the frequency of human M-Igs that exhibit NAb-like activity in patients with monoclonal gammopathies and to explore possible correlations with their clinical features. Thus, 151 M-Igs (124 of IgG class: 71IgG-kappa/53 IgG-lambda and 27 of IgA class: 16 IgA-kappa/11 IgA-lambda) from patients with symptomatic multiple myeloma (MM; n=136), asymptomatic MM (n=8) or MGUS (n=7) and 50 M-Igs from patients with Waldenström Macroglobulinemia (WM) or IgM-MGUS (43 IgM-kappa and 7 IgM-lambda), without any autoimmune diseases, were studied by an in-house ELISA for polyreactivity against six autoantigens (native DNA, actin, tubulin, myosin, carbonic anhydrase, thyroglobulin) and the non-self hapten TriNitroPhenyl (TNP). Sera were also tested for antibody activity against F(ab')2 fragment of human polyclonal IgGs. Most of these antigens are known targets of NAbs. Sera were first screened with enzyme-coupled human heavy chain antibodies (anti-G, anti-M and anti-A), and reactivity–with the exception of anti-F(ab')2–was further attributed to the M-Ig using enzyme-coupled light chain antibodies (anti-kappa and anti-lambda). A significant proportion (18.2%: 35/192 evaluated patients) of pathological sera exhibited anti-F(ab')2 activity (27 from IgG-MM, 3 from IgA-MM and 5 from WM patients). Among the total M-Igs tested, 9.5% (18/189) recognised actin, 8.7% (17/194) carbonic anhydrase, 4.6% (9/194) thyroglobulin, 3.7% (7/186) TNP, 3.5% (7/196) tubulin, 2.5% (5/193) myosin and 1.5% (3/188) DNA. M-Igs reacting with actin, carbonic anhydrase, tubulin, myosin and TNP were found to belong to all three Ig classes (IgG, IgA, and IgM). Among the IgG M-Igs tested, the most frequent reactivity was that for thyroglobulin (7.6%), while among the IgA and IgM M-Igs the highest incidence observed was for actin and carbonic anhydrase (23%, 23% and 16.6%, 15.2%, respectively). Positive IgM and IgG M-Ig had either kappa or lambda light chain in a similar proportion, while positive IgA were mostly IgA-lambda (16/18). A high percentage of positive M-Igs from MM and WM patients were polyreactive (46%), i.e., reacted with at least two panel antigens. Polyreactivity was a prominent characteristic of IgA (6/6) and IgM (9/13) but not of IgG (6/36) M-Ig. Most frequent polyreactivity profile was that for actin, carbonic anhydrase and TNP. There was no significant correlation of immune-related features of symptomatic WM (immune cytopenias, cold agglutinin disease, cryoglobulinemia) or of MM characteristics (ISS, CRAB, LDH, plasma cell infiltration) with any of the detected M-Ig specificities or their NAb-like profile. In conclusion, we report for the first time anti-carbonic anhydrase and anti-TNP activity of the M-Igs from patients with monoclonal gammopathies. We also report high incidence of anti- F(ab')2 activity in the sera of these patients as well as of polyreactive M-Igs. Our findings suggest that the M-Igs with NAb activity might reflect the expansion of a clone normally producing a NAb. To-date, it has been assumed that a naive B-cell is first driven to clonal expansion by antigenic stimulation and that subsequently, an oncogenic stimulus results in malignant transformation. Assuming that certain malignant monoclonal gammopathies arise from the proliferation of a clone normally producing a NAb which recognise F(ab')2 and hence is probably involved in the regulation of the NAbs network, it may also be postulated that this may result in deregulation of this network. Disclosures: No relevant conflicts of interest to declare.

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Patterns of Myeloma (MM) Progression After Autologous Transplant (AHCT) – Biochemical Progression Vs. Clinical Relapse

Blood ◽

10.1182/blood.v118.21.5097.5097 ◽

2011 ◽

Vol 118 (21) ◽

pp. 5097-5097

Author(s):

Robert Frank Cornell ◽

Jonathan Thompson ◽

Leena Varkey Maramattom ◽

Veerpal Singh ◽

Ayman A Saad ◽

...

Keyword(s):

Median Time ◽

Light Chain ◽

Conflicts Of Interest ◽

Bone Lesion ◽

Stage Iii ◽

Clinical Relapse ◽

Serum Free Light Chain ◽

Measurable Serum ◽

Biochemical Progression ◽

M Spike

Abstract Abstract 5097 Background: The uniform response criteria for MM suggest that in clinical practice early biochemical progression (EBP) of MM and clinical relapse (clinREL) be distinguished to identify symptomatic patients requiring therapy. The interval between EBP and clinREL in MM is not well characterized. Biochemical progression in those with intact immunoglobulin MM (IIM) could involve serum free light chain (SFLC) progression or monoclonal component (M spike) progression by serum protein electrophoresis (SPE) or both. ClinREL could precede, be concurrent with or follow tumor marker elevation. Methods: We studied EBP and clinREL in 221 consecutive AHCT recipients for MM between 2005 and 2010. Patients with IIM and measurable M spike and SFLC elevation at diagnosis were analyzed. Patients were uniformly monitored at a single institution with SFLC and SPE every 8–12 weeks. Biochemical progression and clinREL were defined by standard IMWG criteria (Durie el al, Leukemia 2006). ClinREL was defined by new/progressive bone lesion or plasmacytoma, hypercalcemia (>11.5 mg/dl), decrease in hemoglobin ≥ 2 g/dl, rise in creatinine ≥ 2 mg/dl, or indication for new myeloma therapy. Results: 76 patients had clinREL after AHCT, 24 were excluded due to light chain predominant or oligosecretory disease, subsequent AlloHCT or other preemptive treatment. Among 52 evaluable patients, median age was 57 years (42–74), 72% had DSS stage III, 40% ISS stage III, 40% high-risk (HR) MM based on t(4;14), t(14;16), 17q del or karyotypic 13 q abnormality. Median time from AHCT to relapse was 484 days (76–1631). Three temporal patterns of MM recurrence were identified: EBP where SFLC/M spike elevation (or both) preceded clinREL (n=28, 54%); concurrent clinREL and SFLC/M spike elevation (n=22, 42%) or isolated clinREL (4%). The proportion of HR MM was similar among groups. The EBP cohort had superior OS compared to concurrent relapse cohort (log rank p <0.0001). Additionally in the EBP cohort, SFLC elevation alone (39%), M spike progression alone (22%) or concurrent SFLC and M spike (39%) progression could be the initial relapse marker. After isolated SFLC progression, median time to M spike progression was 112 days and to clinREL was 200 days. After isolated M spike progression median time to clinREL was 254 days. After simultaneous SFLC and M spike progression median time to clinREL was 234 days. In these 3 groups, overall time to clinREL after AHCT was longest for patients with M spike progression alone (17.8, 20.5 and 36.8 months, respectively; p=0.05). This was due to HR MM being more common in the first 2 groups (45% for isolated SFLC and 37% in the simultaneous SFLC/M spike group). Discussion: In this cohort of relapsed MM after transplant, 54% had isolated early biochemical progression prior to clinREL and this pattern predicted for superior survival. The category of clinREL may not be detected in advance in about one half of patients and predicts for more aggressive relapse. Present guidelines do not recommend SFLC monitoring for relapse in IIM patients with measurable serum M spike. Based on the above data early SFLC progression was seen in 20% of relapses and identified a higher risk subgroup within those with biochemical progression preceding clinREL. Disclosures: No relevant conflicts of interest to declare.

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Five-Years' Follow-up Study for Frequency of Monoclonal Gammopathy of Undetermined Significance (MGUS) in a Korean Elderly Urban Cohort

Blood ◽

10.1182/blood.v120.21.5007.5007 ◽

2012 ◽

Vol 120 (21) ◽

pp. 5007-5007

Author(s):

Soo-Mee Bang ◽

Jeong-Ok Lee ◽

Jung Han Song ◽

Tae-Hee Kim ◽

Ki Woong Kim ◽

...

Keyword(s):

Light Chain ◽

Conflicts Of Interest ◽

Early Death ◽

M Protein ◽

Mild Anemia ◽

And Gender ◽

Elderly Koreans ◽

Korean Elderly ◽

Second Wave

Abstract Abstract 5007 We previously reported the prevalence of MGUS in a Korean Elderly Urban Cohort recruited from 2005 to 2006 (First Wave, Park HK Am J Hematol. 2011;86:752–5). Their plasma samples were screened using immunofixation and free light chain (FLC) assays. Age and gender-adjusted prevalence rates of MGUS were estimated as 3. 3% (95% CI=2. 0–4. 6%), and the age-adjusted prevalence of MGUS was 4. 3% in men (95% CI=1. 9–6. 6%) and 2. 6% in women (95% CI=1. 0–4. 2%). And then we followed them and collected their serum between 2010 and 2011(Second Wave). Among 1, 000 participants of First Wave, 497 participated to the Second Wave and 419 agreed with the donation of serum for protein electrophoresis, immunofixation and FLC assays. Causes of nonattendance were death in 200 (40%), refusal in 197 (40%), move to other area in 69 (14%), and impossible contact in 37 (7%). The frequency of MGUS in Second Wave was 3. 10% (95% CI=1. 44–4. 76%) in all, 4. 27% (95% CI=1. 54–6. 99%) in men, and 1. 92% (95% CI=0. 06–3. 79%) in women. Among 35 MGUS patients in First Wave, 11 were followed. Eight of 11 had persistent MGUS and other 2 showed the disappearance of M protein in Second Wave. The last one showed mild anemia with persistent M protein of 1. 4g/dL suggestive of progression to MM, but was not confirmed because of early death just after Second Wave. Additional 4 MGUS newly developed in Second Wave among 408 persons without MGUS at First Wave. The mean amount of M protein in 13 patients with MGUS was 0. 55g/dL (range: 0. 2∼1. 4). Subtypes of M protein were predominantly A and G in 8 and 5 patients. Light chain was lambda, kappa and none in 8, 4, and 1 patient. Abnormal ratio of FLC was correlated with the presence of MGUS (p=0. 000). In conclusions, the frequency of MGUS is persistently lower in elderly Koreans (3. 1%) than other races. Disclosures: No relevant conflicts of interest to declare.

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