This document provides an overview of plasma cell disorders including monoclonal gammopathy of undetermined significance (MGUS), smoldering myeloma (SMM), symptomatic multiple myeloma, solitary plasmacytoma, Waldenstrom's macroglobulinemia, and primary light chain amyloidosis. It discusses diagnostic criteria and risk factors for progression. Treatment options for active myeloma are outlined including novel agents like thalidomide, bortezomib, and lenalidomide used in various combinations. High-dose chemotherapy with autologous stem cell transplantation improves outcomes.
Plasma cell disorders is a difficult topic where most residents and students confuse with regarding to differentiating between various types of para-proteinemias or plasma cell dyscrasias. This simple presentation will highlight the key points in differentiating, diagnosing these orders. Initial management principles are discussed as well.
It is a neoplasm of B-cell lineage; proliferation of the cells forms a monoclonal population of plasma cells and produces a single type of Ig/Ig fragment.
Plasma cell disorders is a difficult topic where most residents and students confuse with regarding to differentiating between various types of para-proteinemias or plasma cell dyscrasias. This simple presentation will highlight the key points in differentiating, diagnosing these orders. Initial management principles are discussed as well.
It is a neoplasm of B-cell lineage; proliferation of the cells forms a monoclonal population of plasma cells and produces a single type of Ig/Ig fragment.
There are several important changes in the WHO 5th edition hemato-lymphoid with a paradigm shift towards genetic diagnosis along with morphological aspects. Precursor lesions of Clonal hematopoiesis, CHIP and CCUS are formally included, Changes include those in AML, MPN, JMML is now a part of MPN, MDS-MPN, ALAL etc.
What is Acute Lymphoblastic Leukemia?
Acute Lymphoblastic leukemia (ALL), is a cancer that starts from white blood cells called lymphocytes in the bone marrow (the soft inner part of the bones, where new blood cells are generated).
http://www.bmthospitalindia.com/Adult-Acute-Lymphoblastic-Leukemia.html
There are several important changes in the WHO 5th edition hemato-lymphoid with a paradigm shift towards genetic diagnosis along with morphological aspects. Precursor lesions of Clonal hematopoiesis, CHIP and CCUS are formally included, Changes include those in AML, MPN, JMML is now a part of MPN, MDS-MPN, ALAL etc.
What is Acute Lymphoblastic Leukemia?
Acute Lymphoblastic leukemia (ALL), is a cancer that starts from white blood cells called lymphocytes in the bone marrow (the soft inner part of the bones, where new blood cells are generated).
http://www.bmthospitalindia.com/Adult-Acute-Lymphoblastic-Leukemia.html
It is important to note that standard cancer treatments (surgery, chemo/radiation) can always be optimized and improved and many examples exist of life enhancing advancements for almost every type of cancer.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Introduction to AI for Nonprofits with Tapp NetworkTechSoup
Dive into the world of AI! Experts Jon Hill and Tareq Monaur will guide you through AI's role in enhancing nonprofit websites and basic marketing strategies, making it easy to understand and apply.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
For more information, visit-www.vavaclasses.com
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Synthetic Fiber Construction in lab .pptxPavel ( NSTU)
Synthetic fiber production is a fascinating and complex field that blends chemistry, engineering, and environmental science. By understanding these aspects, students can gain a comprehensive view of synthetic fiber production, its impact on society and the environment, and the potential for future innovations. Synthetic fibers play a crucial role in modern society, impacting various aspects of daily life, industry, and the environment. ynthetic fibers are integral to modern life, offering a range of benefits from cost-effectiveness and versatility to innovative applications and performance characteristics. While they pose environmental challenges, ongoing research and development aim to create more sustainable and eco-friendly alternatives. Understanding the importance of synthetic fibers helps in appreciating their role in the economy, industry, and daily life, while also emphasizing the need for sustainable practices and innovation.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Acetabularia Information For Class 9 .docxvaibhavrinwa19
Acetabularia acetabulum is a single-celled green alga that in its vegetative state is morphologically differentiated into a basal rhizoid and an axially elongated stalk, which bears whorls of branching hairs. The single diploid nucleus resides in the rhizoid.
7. Criteria for Diagnosis of Myeloma
MGUS
<3 g/dL M spike
<10% PC
AND
Smoldering MM
3 g M spike
OR 10% PC
Symptomatic
Myeloma
10% PC
+/- M-spike
AND
NO CRAB ≥ 1 CRAB:
Calcium elevation,
Renal dysfunction
Anemia (Hgb <10)
Bone lesions
8. Ultra High Risk SMM = Active Myeloma
Not CRAB but now SLiM CRAB
•S (60% PCs)
•Li (Light chains I/U Ratio >100)
•M (MRI >1 focal lesion)
•C (calcium elevation)
•R (renal insufficiency)
•A (anemia)
•B (bone disease) Lancet Oncology 11/2014
9. Risk Factors for Progression of MGUS to MM
• M-spike > 1.5 g/dL
• Non-IgG Subtype (IgA or IgM)
• Abnormal Serum Free Light Chain Ratio
Any of these 3 factors (or CRAB) warrants a BM Bx,
imaging, and closer follow-up
IgG 1% per year, IgM MGUS 1.5% per year
Rajkumar et al., Blood 2005 and Blood Reviews 2007.
Risk Factors for Progression of SM to MM
• M-spike > 3 g/dL
• PCs >10%
• Abnormal Serum Free Light Chain Ratio
10. Probability of Progression to Active/Symptomatic
MM in pts with Smoldering MM or MGUS
Kyle RA et al. N Engl J Med 2007;356:2582-2590
These patients DO NOT require treatment!!
(unless the progress to Symptomatic MM).
Many NEVER require treatment!
11. Management of MGUS and SMM
MGUS:
– Avg 1% per year progression to MM
– If NO risk factors, repeat labs in 6 mo and
then q 1-2 years
– If any risk factor, repeat labs q 6 mo x 1 yr
and then yearly
Smoldering MM (Stage I):
– Avg 10% per year prog to Sx MM
– Repeat labs q 3-4 months
– Skeletal survey yearly
12. Multiple Myeloma Classic Triad
M-Spike
>10% Malignant Clonal Plasma
Cells in Bone Marrow
Lytic Bone
Lesions
13. Durie-Salmon Staging System for Myeloma
Stage Criteria
I All of the following:
Hemoglobin >10 g/dL
Serum calcium level normal
Normal bones or solitary plasmacytoma on X-Ray
Low M component production rate:
IgG <5 g/dL; IgA <3 g/dL
Bence Jones protein <4 g/24 hr
(Smoldering Myeloma – does not need treatment)
II Not fitting stage I or III
III One or more of the following:
Hemoglobin <8.5 g/dL
Serum calcium level >12 mg/dL
Lytic bone lesions on x-ray
High M-component production rate:
IgG >7 g/dL; IgA >5 g/dL
Bence Jones protein >12 g/24 hr
Durie B, Salmon S. Cancer. 1975;36:842; Multiple Myeloma Research Foundation.
Subclassification Criteria
A Normal renal function (serum creatinine level <2.0 mg/dL)
B Abnormal renal function (serum creatinine level 2.0 mg/dL)
14. Greipp PR, et al. Blood 2005
INTERNATIONAL STAGING SYSTEM
16. Multiple Myeloma Facts
2nd most common Hematologic Malignancy
~30,330 people Dx with MM in 2016 in US
65,000 people in the US living with myeloma
12,650 MM patients die each year in US
Median age at Dx 65-68 years (only 4% <45)
Incidence twice as high in African Americans
17. More frequent in men (1.3:1)
bone/back pain, fatigue/anemia or infections
This disease remains incurable in most patients
Median survival with older therapies 3yrs, with
transplant 5-7 years, and with novel therapies +
transplant probably 8-10 years (see graph)
M protein seen in 99% of cases in serum and/or
urine, IgG > 50%, IgA 20-25%, IgE/IgD 1-3%,
light chain only 5-10%, 1% nonsecretory
Multiple Myeloma Facts
18. Management of
Active/Sympotomatic MM
Those patients with CRAB (Stage II or III
Disease) need treatment
Even Active MM outcomes can vary widely,
and there are many treatment options
– Need to stratify prognosis based on risk
factors and whether or not the pt is a stem
cell transplant candidate
– mSmart System
20. Year Milestone Notes
1962
Melphalan-
prednisone (MP)
Introduction of melphalan in the 1960s associated with
improved survival. More intense chemotherapy
regimens increased response rates, but no
improvement in survival compared to MP
1996 Autologous SCT
Several randomized trials demonstrated a survival
advantage for ASCT compared to conventional
chemotherapy (CCT).
1999
Thalidomide
(Thalomid)
First IMID: Improved response rates and PFS compared
to dexamethasone alone. When added to MP, it
improves survival compared to MP alone
2003
Bortezomib
(Velcade)
First Proteasome Inhibitor (PI): improves survival
compared to high-dose Dex in relpased MM, and VMP
improves survival in newly Dx pts compared to MP
2006
Lenalidomide
(Revlimid)
2nd Gen IMID: Given with weekly dex, improved survival
compared with dex in relapsed myeloma
2012
Carfilzomib
(Kyprolis)
2nd Gen PI: 22% Response rate if refractory to both Vel
and Rev. Also KRd better than Rd, updated approval in
2015
2013
Pomalidomide
(Pomalyst)
3rd Gen IMID: 30% Response rate if refractory to both
Vel and Rev (Only works if given with weekly Dex)
MAJOR MILESTONES IN MYELOMA THERAPY
21. Year Milestone Notes
2015
Panobinostat
(Farydak)
Pan Histone Deacytylase Inhibitor. Approved in combination
with Velcade for Relapsed MM
2015 Ixazomib (Ninlaro)
First Oral Proteasome Inhibitor: Given once weekly days
1/8/15 along with Rev and Dex for relapse. Much less
neuropathy risk.
2015
Daratumumab
(Darzalex)
Anti-CD38 Monoclonal Antibody. 29% Response rate
alone. (Also can be combined with Rev or Pom per ASH
data and Vel per ASCO data). Initially Required 3 prior
Lines of Therapy
2015
Elotuzumab
(Empliciti)
Anti-SLAMF7 (CS1) Monoclonal Antibody. Must be given
along with IMID such as Revlimid for activity. Requires
only 1 prior line of therapy
2015
Carfilzomib
(Kyprolis) updates
Approved as triple therapy with KRd (superior outcomes in
Aspire vs Rd) and also as high dose 56 mg/m2 (superior
outcomes in Endeavor vs Vd)
2016
Daratumumab
updates
Approved as triple therapy with Len/dex and Vel/dex for 2nd
line therapy
2017
Lenalidmide
Maintenance
Approved
MAJOR MILESTONES IN MYELOMA THERAPY
22. Therapeutic algorithms for newly diagnosed
patients with plasma cell myeloma
Induction Consolidation
Front line treatment
Maintenance
Maintenance
Salvage
Relapsed
Rev/Dex, Vel/Dex
RVD, VCD
CTD, VTD, VDD,
MPT, MPV, MPR
Auto-SCT
None
Rev
Thalidomide
Prednisone
Velcade
Clinical Trial
Whatever worked
before or
haven’t tried
23. International Myeloma Working Group
Uniform Response Criteria
Durie BGM, et al. Leukemia. 2006;20:1467-1473.
PR: ≥ 50% reduction in serum M-protein
VGPR: > 90% reduction in M-protein
Near CR: Negative SPEP/UPEP but POSITIVE Immunofixation
(Faint monoclonal band but too small to quantitate)
CR: Negative SPEP AND Negative Immunofixation (serum and urine)
Stringent CR: CR + Normalization of free light chain ratio
(serum free light chain assay), <1% plasma cells (NOW
proposing new criteria for absence of aberrant cells on flow
cytometry due to better survival in these pts)
Anything VGPR or better considered a “Deep Remission”
24. Autologous peripheral blood stem cells collected by
apheresis, frozen, later used as a “rescue” from marrow
ablative effect of high dose chemo
Introduced in the 1980’s, several randomized trials in the
1990’s and early 2000’s using high dose melphalan and
ASCT showed improved PFS and Overall Survival
Generally see 1-2 year survival increase compared to
conventional chemotherapy
SOC since the 1990’s and remains today
Attal M, et al. N Engl J Med 1996;335:91-7. Child JA, et al. N Engl J Med 2003:1875-83.
High Dose Chemotherapy with
Autologous Stem Cell Transplantation (ASCT)
25. 54
42
Attal M, et al. N Engl J Med. 1996;335:91-97. Child JA, et al. N Engl J Med. 2003;348:1875-1883.
15 30 45 60
25
50
75
100
OS(%)
0
0
High dose (ASCT)
Conventional dose
Mos
20 40 60 80
25
50
75
100
Survival(%)
0
0
High Dose (Auto SCT)
Standard therapy
Mos
P = .03
ASCT vs Conventional
Chemotherapy
26. At our transplant center we transplant Myeloma
patients up to age 75, depending on comorbidities
Generally done after 3-6 cycles of induction therapy
but also possible to store stem cells and hold off on
transplant until later relapse
Tandem ASCT subgroup analysis shows benefit only
in pts not achieving VGPR after first SCT
Allogeneic SCT may “cure” small subset of patients
but very toxic due to GVHD and no clear benefit over
Auto
Attal M, et al. N Engl J Med 2003;349:2495-502
ASCT, cont’d
27. NOVEL THERAPIES
• Not traditional chemotherapy (which
kills both cancer and healthy cells by
attacking cell division)
• These drugs target the cancer cells by
attacking other pathways besides cell
division and are more cancer specific,
often less toxic
28. Thalidomide (Thalomid)
First “Novel Agent” (non-chemo) routinely used for
therapy of myeloma (other than steroids) (ORAL!)
Several Mechanisms:
Stimulation of T-cells and natural killer cells
(Hence the term “Immunomodulatory” agent = IMiD)
Anti-angiogenesis properties (decreased VEGF)
Suppress Myeloma growth factors: IL-6, TNF-alpha
Inhibits myeloma cell adhesion to stroma
Side Effects:
Teratogenic!!
Peripheral Neuropathy!!!
DVT/PE (requires full anticoag),
Constipation, and Sedation
30. Bortezomib (Velcade)
First-in-class proteasome inhibitor, approved 2003 (IV)
Potentiates sensitivity of myeloma to both
conventional and novel therapeutic agents (IV or SQ)
Mechanism of action
– Reversible inhibitor of 26S proteasome
– Inhibition of proteasome prevents proteolysis of ubiquitinated
proteins
– disrupts homeostasis, leads to apoptosis
– Overcomes t(4;14) and del 13q (now intermediate) but not 17p
Side Effects:
• Peripheral Neuropathy!
• Decreased by SQ or q week
Decreased Plt or WBC
Zoster due to IC
31. Armand J et al. The Oncologist 2007;12:281-29
PROTEASOME INHIBITION BY BORTEZOMIB.
32. Lenalidomide (Revlimid)
FDA approved in 2005
More “potent” immunomodulator than thalidomide
Up to 50,000 times more potent inhibitor of TNF
Fewer side effects compared to thalidomide:
no neuropathy, less constipation, less VTE (ASA
prophylaxis), and sedation; more
myelosuppression/cytopenias
May be teratogenic so same safety precautions
Oral (d1-21, 1 wk off)
Schey SA et al. J Clin Oncol. 2004;22:16
Richardson P, Anderson K. J Clin Oncol. 2004;22:16
36. Combinations of Novel Agents
3 Drug Regimens (especially those that have 2
novel agents) improves response rates and
chances of deep remission
VRD and CyBorD (VCD) are very well tolerated and
97% response rates
Adding a 4th drug (VRCD, VMPT) may slightly
increase response rate but increases toxicity and
not yet shown to have survival benefit
All patients will eventually relapse
40. Tetrapeptide epoxyketone
Novel proteasome inhibitor
– Binds irreversibly, given by IV infusion (2 d/wk)
Active in 22% of MM pts refractory to Velcade and
Revlimid (and may be more powerful than velcade
in up-front therapy but studies ongoing)
Mainly Hematologic toxicity, Peripheral Neuropathy
RARE (despite being similar to Velcade)
FDA Approved July 2012 (only for those that are
relapsing after prior velcade and revlimid)
2015 approved in combo with Rev/dex
Carfilzomib (Kyprolis)
1. Kuhn DJ, et al. Blood. 2007;110:3281-3290. 2. O’Connor OA, et al. Clin Cancer Res. 2009;15:7085-
7091. 3. Vij R, et al. Blood. 2012;[Epub ahead of print].
Carfilzomib
O O O O
O O
O
N N
H
N
H
H
N
H
N
41.
42. New IMiDs (more potent, less toxic)
Pomalidomide - 30% Response in Rev and
Vel-Refractory pts (FDA approved 2/2013)
43. 3 Recently approved Therapies
New Proteosome Inhibitors (ORAL)
Ixazomib (Ninlaro) – weekly pill combined
with Rev/Dex in relapsed pts (Triple Oral
Therapy without neuropathy!!!)
Monoclonal Antibodies targeting PCs
Daratumumab (monoclonal antibody targeting
CD38), single agent responses 29%, combined
with Imid OR Velcade 83-93% (initially 4th line
but now 2nd line therapy!)
Elotuzumab (Anti-CS1/SLAMF7) ~ 80%
Response in Relapsed pts combined with
Rev/dex but not alone (activates NK cells)
44. Supportive Care
Don’t Forget:
Bisphosphonates
Monthly 1st year, then q 3 months 2nd year
– Dental eval before starting to avoid needing dental
extractions and risk of ONJ
Surgery (repair impending hip fractures)
Kyphoplasty/Vertebroplasty for compression Fx
Acyclovir with Velcade
Dialysis
Collect stem cells before too much myelotoxic
therapy (Avoid Mel or >4 cycles of Rev)
45. Conclusions
Between the 60’s and 90’s there was nothing better than
MP for Myeloma and survival was dismal
Survival improved with high dose chemo and ASCT
No new MM drugs approved for 4 decades from the 60’s
until 2003 but now we have 4 highly active Novel agents
approved over the past 9 years
Survival is Improving in Myeloma with combinations of
Novel Agents and Auto SCT over the past decade
Although we have effective therapies, all MM pts relapse
and become refractory to all therapies so we need more
Not known if combinations of these new drugs will make
myeloma curable vs a chronic disease
46. Topics if time allows:
Plasmacytoma
Amyloidosis
Waldenstrom’s and POEMS
47. PLASMACYTOMA
Can be solitary or multifocal
Can arise in bone or soft tissue (Extramedullary)
Most common EM location is the upper resp tract
(80%), 10yr DFS 70-80%. (10-15% develop MM)
Bone plasmacytomas higher risk of progression to
MM (10yr DFS 25-50%)(50-60% develop MM)
Treatment of solitary is local radiation +/- surgery
(The only curable plasma cell disorder)
Multifocal plasmacytomas treated like myeloma.
48. AL Amyloidosis
Deposition of fibrillar light chains in tissues that is
detected by Congo red staining (green birefringence)
Median age at presentation 65yrs, med survival 13mo
Can be localized or systemic (primary systemic
amyloidosis)
Range of presentation: nephrotic syndrome,
cardiomyopathy, macroglossia, neuropathy, skin lesions
Dx based on biopsy and presence of M spike in serum or
urine and Mass Spec at Mayo for subtyping.
No systemic treatment needed for localized deposits,
only symptom relief
Systemic disease treated similar to myeloma (Auto
PBSCT or novel agents like Velcade).
Worse prognosis if elevated BNP, troponin, septal
thickness >13mm, multiple organ dysfxn
51. - 94% response rate, 71% complete hematologic response,
24% partial response
- Time to Light Chain response was 2 months but organ
response 6 months.
- 3 pts originally not eligible for ASCT became eligible .
- 50% had a 50% decrease in proteinuria.
- Of the 7 pts monitored for cardiac biomarkers, 5 improved
(with 3 normalized)
52.
53. Characteristic combination of :
Monoclonal IgM protein (Immunoglobulin) secretion
Infiltration of the bone marrow with clonal
lymphoplasmacytic Lymphoma (LPL) cells
90% have mutation in MyD88 gene in the LPL cells
1% are Non-IgM and called LPL but not WM
Cause Unknown but can run in families in 20%
Diagnosis of Waldenström’s Macroglobulinemia (WM)
aka Lymphoplasmacytic Lymphoma (LPL):
54. Signs/Symptoms of WM/LPL
Low blood counts (Marrow replacement)
• Anemia (Hgb <10) or Low platelets (Plt <100)
Hyperviscosity (Sludging due to very high IgM)
• Dizziness, blurry vision, nose bleeds (Medical
Emergency)
Enlargement of spleen, liver or bulky lymph nodes (>5cm)
4% with Neuropathy (anti-MAG, Sulfatide, GM1, etc)
Cold Agglutinins or Cryoglobulins (monoclonal)
Fevers/Night Sweats/Weight Loss
Systemic Amyloidosis
55. Therapy for Symptomatic
Waldenström’s Macroglobulinemia
No treatment for Smoldering WM (Risk of progression
similar to SMM 4-10% per year)
Plasmapheresis for temporary control of hyperviscosity
First-line treatment options in WM
– Alkylating agents, rituximab, proteasome inhibitor, steroids
Best response w/ combination Bendamustine/Rituximab,
Cytoxan/Rituxaimab, Bortezomib/Rituximab/Dex
Single agent Rituxan VERY effective and minimally toxic
Avoid single agent Rituxan if IgM >5000 due to >50%
risk of IgM “Flare”
Ibrutinib (btk inhiitor) approved 2012 (oral tki) and the
ONLY FDA approved therapy for WM
57. Criteria for the diagnosis of POEMS syndrome
Mandatory major criteria (both required)
Polyneuropathy
Monoclonal plasma cell proliferative disorder (95% are lambda)
Other major criteria (one required)
Sclerotic bone lesions
Castleman's disease
Elevated levels of vascular endothelial growth factor (VEGF)*
Minor criteria (one required)
Organomegaly (splenomegaly, hepatomegaly, or lymphadenopathy)
Extravascular volume overload (edema, pleural effusion, or ascites)
Endocrinopathy (adrenal, thyroid, pituitary, gonadal, parathyroid,
pancreatic, DM)•
Skin changes (hyperpigmentation, hypertrichosis, hemangiomata,
plethora, acrocyanosis, flushing, white nails)
Papilledema
Thrombocytosis/polycythemia
The diagnosis of POEMS syndrome is confirmed when both of the mandatory major criteria,
one of the three other major criteria, and one of the six minor criteria are present.
• In order to consider endocrinopathy as a minor criterion, an endocrine disorder other than diabetes or
hypothyroidism is required since these two disorders are common in the general population.
58. • VEGF mediated in part (not the paraprotein)
• Both sensory and motor symptoms are
distal, symmetric, progressive
• Severe weakness in >50%, chronic
inflammatory demyelinating
polyneuropathy.
• Sural nerve Bx usually shows both axonal
degeneration and demyelination
• Response to therapy based on (IFE, light
chains, VEGF level), imaging studies (if PET
avid mass), and later symptom
improvement.
• Neuropathy takes ~3 months to stabilize, 6
mo to begin to improve, 2-3 yrs for max
improvement after SCT
POEMS syndrome
59. Case #1
55 y/o WF with h/o early Breast Cancer 2001
(lumpectomy/radiation, aromatase), early
Uterine Cancer 1999 (TAH/BSO), hypothyroid,
on routine f/u late 2008 noted to have elevated
total protein 8.9, globulin 4.9 (actually stable)
Further workup showed M-spike 2.4 IgM Kappa,
Total IgM 3630, Free Kappa 93.1mg/L, K/L 50.9,
Viscosity 1.9, Beta 2 Micro 2.6, Hgb 12.4, Plt 339
Bone Marrow Bx done 1/2/09: LPL involving
50% of cellularity, aspirate diff shows 31%
Lymphs + 8% PCs, Flow shows clonal Kappa
Restricted LPL
What Treatment would you start??
60. Case #1, cont’d
No Splenomegaly, bulky adenopathy,
Cytopenias, B-Symptoms, hyperviscosity,
Neuropathy, skeletal survey neg, CT C/A/P
neg
Therefore “Smoldering WM” and NO need
for treatment
Watch and wait with repeat labs and
checkup every 3 months the 1st year, q4
months the 2nd year, then at least every 6
months if stable with no progression
Graph of IgM and M-spike …….
62. Case #2
80 y/o WF with increasing back pain,
osteoporosis, compression fractures but no
lytic lesions. Workup showed anemia w/
Hgb 9.5, elevated total protein, M-spike >
3 g/dL
Referred for Treatment of “Multiple
Myeloma”
63. Case #2
Don’t forget to do the immunofixation and
quantitative immunogloblins:
IgM 6380, M-spike 3.6 g/dL IgM Lambda, Hgb
9.1, viscosity 2.3, Beta 2 Micro 4.74, Lambda 60
BMBx showed similar findings to the previous
case with 54% Lymphoplasmacytic Infiltrate.
Imaging confirmed several compression fractures
and osteoporosis but NO lytic lesions
64. Case #2, cont’d
IgM >5000 but elderly, no hyperviscosity,
tried the oral cytoxan in combination with
Rituxan (DRC) but had terrible nausea with
one dose of oral cytoxan so changed to
single agent Rituxan and did well without
flare
4 weekly doses followed by another 4
weekly doses 3 months later (weeks 12-
15)
Graph of IgM …….
65. Case #2
IgM Over Past 6 Years
Rituximab 4 wkly doses repeated at 3 months apart
(2/09, 5/09 followed by 3 year remission, then 2/12, 5/12
now 1 dose q 3 mo Maintenance)
IgM Continued to Improve
on Maintenance
Q 3 month dosing, off
maintenance 3 years and
IgM 120 now (normal 230)
66. Case #3
62 y/o WF (Daughter of Case #2)
Was seeing PCP at UTSW for back pain and URI, found to
have elevated total protein
1/6/14: Returned to PCP for results of SPEP: M-spike 2.27
g/dL. She called me and I saw her for new pt consult same
day expecting to see WM!
Kappa FLC 174, IgM 5686, BMBx showed 30-40% PCs,
Kappa restricted, IgM+, Cyclin D1+, FISH showed t(11;14)
Xrays: subcortical lucency of the left hip greater trochanter,
1.5cm lytic lesion of L1 on PET/CT so Stage IIA IgM
Myeloma
Failed Rev/dex, 92% VGPR to VRD, stable VGPR s/p SCT for
2 years, then failed Ninlaro, Pom, now responding to
Dara/Pom/Dex combo