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Monoclonal gammopathy of neural significance (MGNS) belongs to the category of monoclonal gammopathy of clinically significance. It is an early-stage disease that mainly occurs in peripheral nerves and is not sufficient for the diagnosis of multiple myeloma or lymphoma. MGNS needs to be differentiated from neuropathies due to POEMS syndrome and light-chain amyloidosis; if necessary, nerve biopsy can be performed to clarify the relationship between peripheral nerve symptoms and lymphoplasmacytic disease. Treatment of MGNS is recommended to give intravenous gammaglobulin, plasma exchange and targeted anti-lymphoplasmacytic tumour therapy such as CD20 monoclonal antibody. Early recognition and intervention of MGNS, with multidisciplinary cooperation, will help to reduce the risk of malignancy and the incidence of disability.
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Plasma cell disorders are a group of heterogeneous diseases originating from plasma cells, including multiple myeloma, plasma cell leukemia and light-chain amyloidosis, etc. Monoclonal plasma cells are detected in bone marrow and affected tissues, monoclonal immunoglobulin or components are detected in serum or urine, and some end-organs are injured. Plasma cell disorders accompanied by t(11;14) have unique biological characteristics and unsatisfactory response to proteasome inhibitors. With t(11;14) translocation, the expressions of cyclin D1 and anti-apoptotic protein bcl-2 are relatively high, which lead to the occurrence of plasma cell disorders and have implications for the prognosis of disease. Venetoclax is a bcl-2 inhibitor, and its single agent or combined with other drugs has achieved good efficacy in treatment of plasma cell disorders with t(11;14). This article reviews the progress of bcl-2 inhibitors in treatment of plasma cell disorders.
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Objective:To investigate the expression of serum human phosphatidylethanolamine-binding protein 4 (hPEBP4) in patients with multiple myeloma (MM) and its clinical significance.Methods:A total of 59 symptomatic MM patients admitted to West Branch of Beijing Chaoyang Hospital from September 2016 to September 2018 were selected as the research objects. According to the CRAB symptoms [elevated serum calcium (C), kidney injury (R), anemia (A), bone lesions (B)], all patients were divided into 2 groups, including the active group of 44 patients with CRAB symptoms, and the response group of 15 patients who achieved at least partial remission after chemotherapy and symptom relief of CRAB. According to the degree of bone lesions (BL), 30 patients with severe bone-related events were grouped as the severe bone lesions (SBL) group, and 14 patients were grouped as the non-severe bone lesions (NSBL) group. According to the revised international prognostic staging system (R-ISS), patients in the active group were divided into three subgroups: stage Ⅰ, stage Ⅱ, and stage Ⅲ, including 26, 11 and 7 patients, respectively. A total of 15 healthy examination people whose gender and age matched those of the patients were treated as the healthy control group. Enzyme-linked immunosorbent assay (ELISA) was used to detect the expression levels of hPEBP4, tumor necrosis factor ligand superfamily member 14 (LIGHT/TNFSF14) and activin A of patients in different groups. Pearson was used to analyze the relationship of the expressions of multiple factors in the active group. The optimal cut-off value of multiple factors diagnosing MM was determined by using receiver operating characteristic (ROC) curve, and according to the cut-off value, the differences in overall survival (OS) of patients with different stratification were compared.Results:In the active group, the respond group, the healthy control group, the level of hPEBP4 was (1.48±0.64) μg/L, (1.49±0.75) μg/L, (0.31±0.10) μg/L, respectively; the level of LIGHT/TNFSF14 was (169±112) ng/L, (256±132) ng/L, (44±27) ng/L,respectively; the level of activin A was (383±266) ng/L, (223±79) ng/L, (234±85) ng/L, respectively; and the differences were statistically significant (all P<0.05). In the active group, the level of hPEBP4 was (1.06±0.60) μg/L, (1.15±0.50) μg/L, (1.73±0.68) μg/L, respectively in patients with stage R-ISSⅠ, R-ISSⅡ and R-ISS Ⅲ, and the difference was statistically significant ( F=3.287, P=0.032). The level of activin A was (219±55) ng/L, (247±117) ng/L, (450±215) ng/L, respectively among patients in stage R-ISSⅠ, R-ISSⅡ, R-ISS Ⅲ, and the level of activin A in stage R-ISS Ⅲ was higher than that in stage R-ISSⅠand R-ISSⅡ (all P < 0.05). The levels of LIGHT/TNFSF14 and activin A of SBL patients were higher than those of NSBL patients [(174±101) ng/L vs. (98±53) ng/L; (467±238) ng/L vs. (189±71) ng/L, all P < 0.05]. The level of hPEBP4 was positively correlated with the levels of M protein ( r=0.694, P < 0.01) and activin A ( r=0.252, P < 0.01) of IgG patients in the active group. ROC curve analysis showed that the optimal cut-off value of hPEBP4, LIGHT/TNFSF14, activin A diagnosing MM was 1.04 μg/L, 97.0 μg/L, 156.2 ng/L. The median overall survival (OS) time of patients with hPEBP4 >1.04 μg/L and hPEBP4 ≤ 1.04 μg/L was 57 months (95% CI 22-92 months) and not reached, respectively, and the difference was statistically significant ( P < 0.05); while the median OS time of patients with activin A ≥ 156.2 ng/L and activin A < 156.2 ng/L was 61 months (95% CI 24-98 months) and not reached, respectively, and the difference was statistically significant ( P < 0.05). Conclusions:High expression level of hPEBP4 is related with the progression of MM. It is positively related with the level of M protein and negatively with the OS of MM patients. It is suggested that hPEBP4 may be used as an important marker to judge disease progression and tumor burden in MM. LIGHT/TNFSF14 and activin A cooperate with hPEBP4 to participate in the pathological processes of tumor microenvironment of MM.
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A 49-year-old woman was admitted to hospital with intermittent dizziness and fatigue for 7 years. The symptoms were aggravated and accompanied by bone pain for more than 4 months. She was referred to our hospital. Laboratory tests and imaging findings suggested that acquired Fanconi Syndrome (FS) was associated with smoldering multiple myeloma (MM). Renal biopsy and electron microscopy confirmed the diagnosis of proximal light chain tubular disease (LCPT). LCPT causes proximal tubular dysfunction, which is characterized by the cytoplasmic crystal deposition usually kappa monoclonal light chain in the proximal tubule. MM with FS and LCPT is less common in clinical practice because it is difficult to diagnose. This is a typical case focusing on the differential diagnosis of monoclonal gammopathy of renal significance(MGRS) such as LCPT and plasma cells diseases.
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A 49-year-old woman was admitted to hospital with intermittent dizziness and fatigue for 7 years. The symptoms were aggravated and accompanied by bone pain for more than 4 months. She was referred to our hospital. Laboratory tests and imaging findings suggested that acquired Fanconi Syndrome (FS) was associated with smoldering multiple myeloma (MM). Renal biopsy and electron microscopy confirmed the diagnosis of proximal light chain tubular disease (LCPT). LCPT causes proximal tubular dysfunction, which is characterized by the cytoplasmic crystal deposition usually kappa monoclonal light chain in the proximal tubule. MM with FS and LCPT is less common in clinical practice because it is difficult to diagnose. This is a typical case focusing on the differential diagnosis of monoclonal gammopathy of renal significance(MGRS) such as LCPT and plasma cells diseases.
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Plasma cell leukemia (PCL) is a rare and aggressive malignant plasma cell tumor that is clinically susceptible to extramedullary lesions. It is classified into two types: primary PCL (pPCL) and secondary PCL (sPCL), of which 60 % are pPCL. The treatment of new drugs such as bortezomib and lenalidomide is important for improving the overall survival and disease-free survival of PCL, especially after induction of bortezomib-based chemotherapy,combined with autologous hematopoietic stem cell transplantation (auto-HSCT) can improve the survival of patients. Whether to adopt the next step of allogeneic hematopoietic stem cell transplantation (allo-HSCT) still needs further investigation. For young and suitable patients, early new drug-based regimen chemotherapy combined with auto-HSCT can be used, and if a suitable donor is available, the further allo-HSCT consolidation therapy is feasible. For elderly patients (≥65 years old), a new drug-based regimen can be used to induce chemotherapy, and further followed consolidation therapy plus maintenance therapy. Whether to take auto-HSCT after early induction chemotherapy depends on the individualized factors of the patient. The next generation anti-plasma cells drugs, monoclonal antibodies and other immunotherapies or new drugs in clinical trials are also worth exploring.
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Light chain amyloidosis (AL) is a clonal plasma cell disease in which multiple organs of human body are damaged by amyloid misfolded by light chain of immunoglobulin. Its mechanism is still unclear. Clinically, heart failure, renal insufficiency and other organs failure are seen as prominent symptoms for the majority of patients. The main treatments include melphalan combined with dexamethasone or bortezomib or other target new drugs or autologous stem cell transplantation. Efficacy assessment depends on not only the serum free light chain and M protein levels to judge the hematological response, but also pro-brain natriuretic peptide and troponin I as biomarker to assess the heart and other vital organs function for better outcomes. In the era of new drugs, cardiac involvement is a determinant of survival and prognosis of AL patients. The modern AL treatment usually takes new drug targeted therapy against plasma cells, and combines with anti-amyloidosis treatment to clear the accumulation of amyloidosis chaperonin. Despite the promising advances in treatment, many problems need to be resolved.
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Objective To evaluate the efficacy and safety of lenalidomide in a real-world clinical practice in Chinese patients with multiple myeloma (MM).Methods It was a prospective,multi-center,observational study.A total of 165 consecutive patients with MM treated with lenalidomide-based regimens were enrolled in 12 hospitals from June 2013 to November 2015.Relevant information was recorded,such as baseline clinical data,cytogenetic abnormalities,treatment regimens,and duration of treatment,safety,and survival.Results (1)There were 126 relapsed and refractory MM (RRMM) patients,25 newly diagnosed patients and 19 maintenance patients.The evaluable RRMM patients accounted for 120 cases,among which 74 cases(61.7％) reached the partial response (PR) or above,and a very good partial response (VGPR) in 16 patients (13.3％),a complete response (CR) in 14 cases (11.7％),a strictly complete response (sCR) in 4 cases (3.3％).Thus,a VGPR or above in 34 patients accounted for 28.3％.(2)The median follow-up was 13 months,the median time to progression 12 months.The median survival after receiving lenalidomide was 19 months,and the median overall survival (OS) was 62 months.(3) The univariate analysis in 120 RRMM patients suggested that prognostic factors for significant improvement in PFS included normal karyotype,international staging system (ISS) Ⅰ-Ⅱ,t(4;14) negative (detected by fluorescence in situ hybridization),non-bortezomib resistance and response to previous regimens.As to OS,nonbortezomib resistance,response to previous regimens and non-primary refractoriness were positive factors.Multivariate analysis showed that the response to previous regimens (PR or better) was an independent good prognostic factor for progress-free survival (PFS),non-bortezomib resistance and non-primary refractoriness for OS.(4) Grade 3 or 4 adverse events that occurred in more than 10％ of all enrolled patients were neutropenia (12.7％),leukocytosis (11.5％) and thrombocytopenia (12.7％).Owing to intolerance of toxic side effects,7 cases withdrew lenalidomide.Conclusions No matter what combination,regimens containing lenalidomide are effective to RRMM patients with overall response rate 61.7％,a time to progression 12 months and an overall survival 62 months.The toxicity is quite tolerable and manageable.In addition,the response to previous treatment (reached PR or above) is the independent good prognostic factor for PFS,non-bortezomib resistance and non-primary refractoriness for OS.Clinical trail registration Clinicaltrials.gov,NCT01947309
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Objective:This study investigated the clinical characteristics of multiple myeloma with early death in the era of novel drugs. Methods:Medical records from 188 patients diagnosed from January 2009 to December 2015 were retrospectively reviewed, showing that early death occurred in 19 patients. Early death was defined as death by any cause within the first year after diagnosis. Results:(1) Early mortality was 10.1%, and the median age was 67 years old (range:40-84 years). Eight cases presented IgG type, and 11 cases were non-IgG type. All 19 patients were diagnosed to be at stageⅢin accordance with the Durie–Salmon staging system, and renal insufficiency occurred in 10 patients. In accordance with the International Staging System (ISS), four patients were diagnosed to be at stageⅡ, whereas 15 other patients were at stageⅢ. Extramedullary plasmacytoma (EMP) occurred in six cases, whereas 10 cases pre-sented high-risk patients with cytogenetic abnormalities. Elevated lactate dehydrogenase (LDH) was found in five cases, amyloidosis was detected in three patients, and secondary plasma cell leukemia was observed in two cases. The median score of performance sta-tus (KPS) was 70 (range: 20-80). A total of 16 patients were treated with bortezomib, and 3 patients were treated with CADT. (2) Among the 13 patients who were evaluated, the overall response rate was 46.2%(6/13), and the complete response (CR) and near-CR rate was 7.7%(1/13). (3) The median overall survival was 3 (1-11.5) months, although the two patients with secondary plasma cell leu-kemia survived for less than 2 months. (4) Eight patients died of disease progression (42.1%), eight patients died of severe infections (42.1%), and three patients died of thrombotic events. Conclusion:The important causes of early death include the following:high-risk cytogenetics, elevated LDH, EMP, amyloidosis, advanced age, poor performance status, and serious complications during treat-ment. In the era of novel drugs, we should improve early diagnosis rates and explore individualized treatment for high-risk multiple my-eloma for the benefit of a wide range of patients.
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As understanding the biology of multiple myeloma (MM) and application of new drugs, regimens containing new drugs deepened therapeutic response and prolonged the survival of MM patients. This article updates the therapeutic response of regimens reported in the 57th American Society of Hematology annual meeting, containing immunomodulatory agents, proteasome inhibitors, histone deacetylase inhibitors and other new drugs including monoclonal antibodies and the others. In the same time, minimal residual disease (MRD) is also used to evaluate the remission depth of MM. In order to achieve durable long-term remission and higher quality of life, new drug combination regimens have been recommended, especially for the relapsed or the high risk MM patients.
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Objective To investigate the efficacy and outcome in newly diagnosed multiple myeloma (MM) patients with renal insufficiency using bortezomib-or thalidomide-based regimens as front line treatment.Method Sixty-nine newly diagnosed MM patients with renal insufficiency were retrospectively analyzed from August 2006 to August 2014.Results ① Among thirty-nine patients with bortezomib based regimens (the bortezomib group),the overall response rate (ORR) was 89.7％ and complete response (CR) plus near CR(nCR) rate was 41.0％.By contrast,among thirty patients with thalidomide based regimens (the thalidomide group),the ORR was 83.3％ and CR + nCR rate was 26.7％.There was no significant difference of either ORR or CR + nCR rate between bortezomib and thalidomide groups.② The improvement rate of renal function in bortezomib group and thalidomide group were 87.2％ and 60.0％respectively (P =0.012).The median duration time of renal injury was 45 days in 52 patients with renal function improved,which was significantly shorter compared with 222 days in 17 patients without improvement (P ＜ 0.05).There was no difference of median serum creatinine and creatinine clearance rate between the two groups.③ The median progression-free survival (PFS) and the overall survival (OS) were 18 and 33.5 months,respectively in all patients.The three-year and five-year OS rates were 57％ and 17％,respectively.The median PFS was 19 months in bortezomib group,while it was only 12 months in thalidomide group (P =0.023).The median OS were 36.5 months and 25.5 months respectively,which was no difference (P =0.285).Conclusions The newly diagnosed MM patients with renal insufficiency could get higher ORR and the longer PFS using bortezomib-containing regimens as initial therapy.Meanwhile the improvement rate of renal function and the living quality in patients with bortezomib are better compared with those with thalidomide based treatment.
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Multiple myeloma (MM) is a unique cancer paradigm for investigating the mechanisms involved in the transformation from a premalignant condition (unknown monoclonal gamma globulin,MGUS) into a malignant disease (MM).In its pathogenesis,genotype characteristics of tumor clones which are highly complex and heterogeneous,as well as the dialogue between plasma cells and their microenvironment are equally important and both play a key role in the outcome of the disease.MM will soon no longer be considered as a single disease.A large number of new drug emergence and applications will increase the need for monitoring minimal residual disease (MRD) in prognosis and treatment of MM.New drugs and high-dose chemotherapy with autologous stem cell transplantation applications have been significantly improving the prognosis of MM in the past 20 years.Re-examining the early MM diagnostic criteria and the possibility of early intervention will open up a new therapeutic approach.It is important to find a balance of efficacy,toxicity and cost in order to achieve a cure for this disease.
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Objective To investigate the value of 1q21 amplification in newly diagnosed myeloma patients.Methods Fifty-two cases of newly diagnosed multiple myeloma from June 2008 to June 2010 were enrolled.Fluorescence in situ hybridization (FISH) was used to detect the 1q21 amplification,and the clinical characteristics and treatment response were analyzed.Results 1q21 amplification was discovered in 30 of 52 patients (57.7 ％),Clinical characteristics such as gender,malignant pleural effusion,extramedullary plasmacytoma,bone destruction,β2 microglobulin,ALB,hemoglobin,blood calcium,plasma cell proportion,clinical stage seemed to have no correlation with 1q21 amplification.The 52 patients all received bortezomibbased regimens.The response rates were not significant difference between patients with and without 1q21 amplification,the OS was also not significant difference [26 months (6-30 months) vs 30 months (12-85 months),P =0.409],but the patients with presence of 1q21 gain resulted in significantly shorter PFS [8 months (1-30 months) vs 20 months (3--48 months),P=0.019].Multivariate analysis showed 1q21 with more than two additional genetic abnormalities was an independent prognostic predictor (P =0.031).Conclusion 1q21 amplification is one of the adverse prognostic predictors,the response rate is not significant difference between patients with and without 1q21 amplification in bortezomib-based group,but the 1q21 amplification could result in significantly shortened PFS.
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Pathophysiology of myeloma bone disease is unclear and complex.At early stage,osteoclastic bone resorption is increasing,myeloma cells are dependent upon the cells of bone for growth and survival.With the increase in tumor burden,osteoblast suppression is maintained.Based on the diagnosis of multiple myeloma (MM),conventional morphology,M proteins and skeletal survey are effective approach for diagnosis and monitoring of MM.However,the multiparameter flow cytometry (MFC) has advantage in distinguishing clonal from normal plasma cells.If the patient has significant paraprotein relapse in 2 consecutive measurements separated by no more than two months,the experts of International Myeloma Working Group (IMWG) consider that myeloma therpy should be re-started,even if the symptoms or evidences of new end-organ damage has not yet appeared.For newly diagnosed MM patients who are ineligible for autologous stem cell transplantation,the combination of melphalan,prednisone and with either thalidomide (MPT) or bortezomib (VMP) is the standard treatment option,and then given with lenalidomide and low-dose dexamethasone is gradually developing a new standard continuous therapy.For elderly patients,especially over 75 years old,always have a poor clinic outcome.It should be fully aware that frailty is an independent prognostic factor which carries a greater impact on overall survival than the renal function or cytogenetic abnormalities.Therefore,it must be under consideration in developing individualized treatment programs.
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Background and purpose: Osteopontin (OPN) is a glycophosphoprotein that is expressed by numerous human cancer cells. The function of OPN in skeletal modeling and remodeling, bone resorption, angiogenesis and tumor cell metastasis and progression through binding with integrin and CD44 receptors were studied. Our purpose of the study was to detect the level of osteopontin(OPN) and CD44 variant isoforms(CD44v6) in multiple myeloma (MM) patients, and to explore the relationship between OPN and CD44v6 with the progress of MM. Methods: 32 MM patients were admitted to our hospital from Sep. 2007 to Dec. 2008. The patients were divided into two groups, group A (untreated and relapsed MM patients) and B (stable MM patients), and the control group including 15 subjects were the benign anemia patients or healthy people who suffered bone fracture. Bone marrow mononuclear cells (MNCs) and bone marrow stromal cells (BMSCs) from MM patients and subjects were investigated as potential OPN and CD44v6 producers. The level of OPN and CD44v6 of the conditioned media from MM patients and subjects were analyzed by ELISA. Results: The OPN level in group A (19 cases) was significantly higher than group B (13 cases) and control group (P<0.05). The CD44v6 level of 14 patients in group A was significantly higher than that of 10 cases in group B and control group (P<0.05); The OPN level of MM patients was correlated with the level of CD44v6 (r=0.52, P=0.000), the percentage of plasma cells in the bone marrow (r=0.74, P=0.000), M protein (r=0.53, P=0.014), and β2-microglubin (r=0.62, P=0.002). Conclusion: The increase of OPN and CD44v6 is associated with progress and pathogenesis of MM,and may be involved with tumor burden, stage and tumor invasion.
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<p><b>OBJECTIVE</b>To explore the expression of WT1 gene in leukemia patients and its clinical implications.</p><p><b>METHODS</b>Expression of WT1 mRNA was detected in two leukemia cell lines (K562 and HL-60), 49 acute leukemia (AL) patients, 33 chronic myeloid leukemia (CML) patients and 25 healthy subjects by reverse trans-criptase-nested polymerase chain reaction (RT-Nested PCR).</p><p><b>RESULTS</b>WT1 gene was expressed in all subtype of AL including K562 and HL-60 cell lines, 21/29 newly diagnosed and relapsed AL patients, 1/20 complete remission (CR) AL patients, 15/18 CML blastic crisis patients, 1/5 CML patients in accelerated phase, and 1/10 CML patients in chronic phase. WT1 gene was undetectable in 25 healthy subjects. The expression level of WT1 gene was related to the prognosis of AL, patients with relative level >/= 1.0 had lower CR rates and disease-free survival. For CML patients, WT1 gene expression was associated with the clinical phase, it increased with disease progressed.</p><p><b>CONCLUSION</b>WT1 gene expression is associated with pathogenesis of leukemia. It is a prognostic factor and a marker for the detection of minimal residual disease in AL and may used as an indicator for diagnosing CML blastic crisis.</p>