Alive Patients Research Articles

Peripheral vascular involvement in transthyretin cardiac amyloidosis. A comparative analysis with AL amyloidosis

Abstract Background The pattern of peripheral vascular involvement in the wild type transthyretin-related cardiac amyloidosis (ATTRwt) and its diagnostic utility in differentiating this infiltrating cardiomyopathy from light chain (AL) cardiac amyloidosis (AL-CA) and heart failure with preserved ejection fraction (HFpEF) of different origin have not been explored. Aims To characterize the pattern of peripheral vascular involvement in ATTRwt and evaluate its value in differentiating ATTRwt from AL-CA and HFpEF. Methods Newly diagnosed patients with ATTRwt (n=42) were consecutively recruited from our amyloidosis center. These patients were matched 1:1 for age and sex to patients with AL-CA (n=32) and subjects without amyloidosis (n=32) and also matched 2:1 to HFpEF patients (n=16). All subjects underwent a series of non-invasive vascular examinations for the assessment of: 1. subclinical carotid atherosclerosis with B-mode ultrasonography, 2. Arterial stiffness with measurement of carotid-femoral pulse wave velocity, 3. Reactive vasodilation with flow-mediated dilation (FMD) and 4. Aortic blood pressures and arterial wave reflections with augmentation index (AI) and return time of reflected wave (Tr). Results ATTRwt patients had lower peripheral (pBP) and aortic blood pressure (aBP) markers compared to non-AL controls (p<0.05 for all). ATTRwt grouping was an independent determinant of these markers, after adjustment for cardiovascular risk factors (CVRF), including history of hypertension, hyperlipidemia and diabetes, glomerular filtration rate, body mass index and smoking status (core model). ATTRwt had lower aDBP and increased Tr compared to AL subjects. In a comparison between ATTRwt and AL patients with cardiac involvement, AI and Tr were higher and FMD lower in ATTRwt patients. ATTRwt was an independent determinant of these markers, after adjustment for the core model (p<0.05 for all). Compared to HFpEF, patients with ATTRwt had lower peripheral and central BP and higher Tr (p<0.05 for all). By ROC analysis, Tr provided high diagnostic value for ATTRwt vs. AL-CA (Area Under the Curve, AUC=0.809, CI: 0.65–0.96) and for ATTRwt vs combined AL-CA and HFpEF (AUC=0.880, CI: 0.79–0.97). Finally, AI was closely correlated with posterior (Spearman's Rho=−0.30) and intraventricular wall thickness (Rho=−0.329) and left ventricular global longitudinal strain (Rho=−0.4) and lower cDBP with higher Gilmore and New York Heart Association stage (p<0.05). Conclusion ATTRwt patients present differential characteristics of peripheral vascular function and aortic hemodynamics as compared to AL, HFpEF and healthy controls. The clinical value of these characteristics merit further investigation since differential diagnosis among amyloidosis types is clinically challenging, while it may have prognostic implications. Funding Acknowledgement Type of funding sources: None.

Trends in diagnosis, referral, red flag onset, patient profiles and natural outcome of de novo cardiac amyloidosis and their multidisciplinary implications

Background Cardiac amyloidosis (CA) is often overlooked or misdiagnosed. Effects of growing disease awareness, diagnostic ameliorations and novel treatment options on CA diagnosis and management are scarcely reported. Objective To report trends in diagnosis, referral routes, clinical presentation, early onset diagnostic red flags and outcome in de novo CA subjects. Methods An unselected cohort of 139 de novo CA patients over an 8-year period in a tertiary referral hospital was recruited. Results Transthyretin (ATTR, 82%, n = 114) was the most common CA form; Light-chain (AL, 15%, n = 21) and secondary (AA, 3%, n = 4) are less prevalent. Increased awareness over time led to a marked ATTR diagnostic surge, steep non-invasive diagnostic approach increment and increased nuclear medicine and external cardiologist referrals (all p < 0.001). A total of 41% (n = 57/139) of patients were referred by non-cardiology specialist disciplines. Specific referral to rule out CA (24–36%) and diagnostic time lag from symptom onset (9 ± 12 to 8 ± 14 months), however, did not improve (all p > 0.050). Multiple early red flag events preceded CA diagnose several years in ATTR: Left ventricular hypertrophy (LVH, 60%, 4.9 ± 4.3 y), heart failure (54%, 2.5 ± 3.5 y), atrial fibrillation (47%, 5.9 ± 6.7 y), bilateral carpal tunnel syndrome (43%, 9.5 ± 5.7 y) and spinal stenosis (40%, 7.4 ± 6.5 y). LVH ≥ 12 mm was absent in 11% ATTR (n = 13/114) and 5% AL (n = 1/21) patients. Hypertension was common in both ATTR (n = 70/114, 62%) and AL (n = 10/21, 48%). 56% (n = 78/139) of CA presented with heart failure. Cumulative 1 and 5-year mortality of 10%/66%, 40%/52% and 75%/75% for ATTR, AL, and AA, respectively, remains high. Conclusions Although CA diagnostic uptake and referral improve, specialist-specific disease and diagnostic red flag ignorance result in non-timely diagnosis and unfavourable outcome.

Protease-sensitive regions in amyloid light chains: what a common pattern of fragmentation across organs suggests about aggregation.

Light‐chain (AL) amyloidosis is characterized by deposition of immunoglobulin light chains (LC) as fibrils in target organs. Alongside the full‐length protein, abundant LC fragments are always present in AL deposits. Herein, by combining gel‐based and mass spectrometry analyses, we identified and compared the fragmentation sites of amyloid LCs from multiple organs of an AL λ amyloidosis patient (AL‐55). The positions pinpointed here in kidney and subcutaneous fat, alongside those previously detected in heart of the same patient, were aligned and mapped on the LC’s dimeric and fibrillar states. All tissues contain fragmented LCs along with the full‐length protein; the fragment pattern is coincident across organs, although microheterogeneity exists. Multiple cleavage positions were detected; some are shared, whereas some are organ‐specific, likely due to a complex of proteases. Cleavage sites are concentrated in ‘proteolysis‐prone’ regions, common to all tissues. Several proteolytic sites are not accessible on native dimers, while they are compatible with fibrils. Overall, data suggest that the heterogeneous ensemble of LC fragments originates in tissues and is consistent with digestion of preformed fibrils, or with the hypothesis that initial proteolytic cleavage of the constant domain triggers the amyloidogenic potential of LCs, followed by subsequent proteolytic degradation. This work provides a unique set of molecular data on proteolysis from ex vivo amyloid, which allows discussing hypotheses on role and timing of proteolytic events occurring along amyloid formation and accumulation in AL patients.

Dexamethasone is associated with early deaths in light chain amyloidosis patients with severe cardiac involvement.

Cardiac light chain amyloidosis (AL-CA) patients often die within three months of starting chemotherapy. Chemotherapy for non-immunoglobulin M gammopathy with AL-CA frequently includes bortezomib (Bor), cyclophosphamide (Cy), and dexamethasone (D). We previously reported that NT-ProBNP levels can double within 24h of dexamethasone administration, suggesting a deleterious impact on cardiac function. In this study, we evaluate the role of dexamethasone in early cardiovascular mortality during treatment. We retrospectively assessed 100 de novo cardiac AL patients (62% male, mean age 68 years) treated at our institute between 2009 and 2018 following three chemotherapy regimens: CyBorDComb (all initiated on day 1; 34 patients), DCyBorSeq (D, day 1; Cy, day 8; Bor, day 15; 17 patients), and CyBorDSeq (Cy, day 1; Bor, day 8; D, day 15; 49 patients). The primary endpoint was cardiovascular mortality and cardiac transplantation at days 22 and 455. At day 22, mortality was 20.6% with CyBorDComb, 23.5% with DCyBorSeq, and 0% with CyBorDSeq (p = 0.003). At day 455, mortality was not significantly different between regimens (p = 0.195). Acute toxicity of dexamethasone was evaluated on myocardial function using a rat model of isolated perfused heart. Administration of dexamethasone induced a decrease in left ventricular myocardium contractility and relaxation (p<0.05), supporting a potential negative inotropic effect of dexamethasone in AL-CA patients with severe cardiac involvement. Delaying dexamethasone during the first chemotherapy cycle reduces the number of early deaths without extending survival. It is clear that dexamethasone is beneficial in the long-term treatment of patients with AL-CA. However, the initial introduction of dexamethasone during treatment is critical, but may be associated with early cardiac deaths in severe CA. Thus, it is important to consider the dosage and timing of dexamethasone introduction on a patient-severity basis. The impact of dexamethasone in the treatment of AL-CA needs further investigation.

Longitudinal strain is an independent predictor of survival and response to therapy in patients with systemic AL amyloidosis.

Cardiac involvement, a major determinant of prognosis in AL (light-chain immunoglobulin) amyloidosis, is characterized by an impairment of longitudinal strain (LS%). We sought to evaluate the utility of LS% in a prospectively observed series of patients. A total of 915 serial newly diagnosed AL patients with comprehensive baseline assessments, inclusive of echocardiography, were included. A total of 628/915 (68.6%) patients had cardiac involvement. The LS% worsened with advancing cardiac stage with mean -21.1%, -17.1%, -12.9%, and -12.1% for stages I, II, IIIa, and IIIb, respectively (P < 0.0001). There was a highly significant worsening of overall survival (OS) with worsening LS% quartile: LS% ≤-16.2%: 80 months, -16.1% to -12.2%: 36 [95% confidence interval (CI) 20.9-51.1] months, -12.1% to -9.1%: 22 (95% CI 9.1-34.9) months, and ≥-9.0%: 5 (95% CI 3.2-6.8) months (P < 0.0001). Improvement in LS% was seen at 12 months in patients achieving a haematological complete response (CR) (median improvement from -13.8% to -14.9% in those with CR and difference between involved and uninvolved light chain <10 mg/L). Strain improvement was associated with improved OS (median not reached at 53 months vs. 72 months in patients without strain improvement, P = 0.007). Patients achieving an LS% improvement and a standard N-terminal pro-brain natriuretic peptide-based cardiac response survived longer than those achieving a biomarker-based cardiac response alone (P < 0.0001). Baseline LS% is a functional marker that correlates with worsening cardiac involvement and is predictive of survival. Baseline LS% and an absolute improvement in LS% are useful additional measures of prognosis and response to therapy in cardiac AL amyloidosis, respectively.

Less is More: Deprescribing Medications in Older Adults with Kidney Disease: A Review.

Due to age and impaired kidney function, older adults with kidney disease are at increased risk of medication-related problems and related hospitalizations. One proa ctive approach to minimize this risk is deprescribing. Deprescribing refers to the systematic process of reducing or stopping a medication. Aside from preventing harm, deprescribing can potentially optimize patients' quality of life by aligning medications with their goals of care. For some patients, deprescribing could involve less aggressive management of their diabetes and/or hypertension. In other instances, deprescribing targets may include potentially inappropriate medications that carry greater risk of harm than benefit in older adults, medications that have questionable efficacy, including medications that have varying efficacy by degree of kidney function, and that increase medication regimen complexity. We include a guide for clinicians to utilize in deprescribing, the List, Evaluate, Shared Decision-Making, Support (LESS) framework. The LESS framework provides key considerations at each step of the deprescribing process that can be tailored for the medications and context of individu al patients. Patient characteristics or clinical events that warrant consideration of deprescribing include limited life expectancy, cognitive impairment, and health status changes, such as dialysis initiation or recent hospitalization. We acknowledge patient-, clinician-, and system-level challenges to the depre scribing process. These include patient hesitancy and challenges to discussing goals of care, clinician time constraints and a lack of evidence-based guidelines, and system-level challenges of interoperable electronic health records and limited incentives for deprescribing. However, novel evidence-based tools designed to facilitate deprescribing and future evidence on effectiveness of deprescribing could help mitigate these barriers. This review provides foundational knowledge on deprescribing as an emerging component of clinical practice and research within nephrology.

Development of a conceptual model of patient-reported outcomes in light chain amyloidosis: a qualitative study.

Light chain (AL) amyloidosis is a plasma cell neoplasm associated with high early mortality and severe morbidity that can cause severe disability. We explored the impact of AL amyloidosis on symptoms and well-being from the perspectives of patients and health care providers who regularly care for AL patients. We intended to develop a conceptual understanding of patient-reported outcomes in AL amyloidosis to identify the context of use and concept of interest for a clinical outcome assessments tool in this disease. Twenty patients and ten professionals were interviewed. Patient interviews captured the spectrum of amyloidosis experience including time from diagnosis, type of organ involvement, and presence and type of treatment received. Interviews with professionals included physicians, advanced practice providers, registered nurse, and a patient advocate; these interviews covered similar topics. The impact of AL amyloidosis on patients' life was multidimensional, with highly subjective perceptions of normality and meaning. Four major themes from patients and experts included diagnosis of AL amyloidosis, living with AL amyloidosis, symptom burden, and social roles. Barriers to patient-reported outcomes data collection in patients were additionally explored from experts. The themes provide a comprehensive understanding of the important experiences of symptom burden and its impact on daily life from AL amyloidosis patients' and from the perspectives of professionals who care for patients with AL amyloidosis. These findings further the conceptual understanding and identification of a preliminary model of concept of interest for development of a clinical outcome assessments tool for AL amyloidosis.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

Simultaneous Analysis of Telomere Lengthes and Cell Surface Antigen in Leukemia by Multicolor Flow-FISH

During the last decade telomere length (TL) and telomerase have been discovered as new biological markers and potential new targets of cancer including malignant hematopoietic disorders. A FLOW-FISH method, i.e. quantitative fluorescence in situ hybridization (Q-FISH) in combination with flow cytometry (FCM), has been developed recently. Most overseas studies detect TL by FLOW-FISH without combined analysis of cell immunophenotype. We analyzed TL and cell immunophenotype simultaneously in the same sample by FLOW-FISH in order to combine the two markers to found one generally applied method for monitoring disease conditions or predicting clinical outcome in leukemia.Methods:HL60, Raji, Molt4 cells were cultivated. Each step and the conditions of the FLOW-FISH procedure were optimized, standardized and validated. The relative TL (RTL) of the leukemic sample cells compared to the control cells(Molt4).BM samples were derived from 34 leukemia patients. 20 normal PB samples from healthy individuals were set as control group.The BM or PB MNC were collected and used for FLOW-FISH. Meanwhile, the RQ-PCR measurements in the same samples were performed to test the correlation of the two methods.Results:Using various cell lines, multicolor FLOW-FISH was also successfully established.The median of RTL in 24 AL patients was 0.240, 2 CLL was 0.235, 3 CML-BP was 0.249, 5 CML-CP was 0.435, while that in 20 normal controls was 0.408.(P=0.001). The TL was shorter in patients with AL, CLL, CML-BP than in normal controls, otherwise, the CML-CP cases had no difference with the controls. 14 AL patients had the significantly longer telomere with clinical remissions than at impetus stage (P=0.01), and no significant difference was found between the 12 cases with clinical remissions and the normal controls(P=0.363). A high degree of correlation between the RTL obtained from FLOW-FISH and TL estimation by RQ-PCR existed (P=0.000).There was a significant negative correlation between TL and age in 20 normal controls(P=0.001), and the female had longer telomere than the male(P=0.037). However no statistic difference between TL and age or gender existed in 34 de novo leukemia patients. The TL of 24 AL cases had a negative correlation with peripheral white cells counts(P=0.002). Within 23 follow-up AL patients, the CR rate in cases with TL above the median was 81.82%, and 58.23% in the rest. Among 5 CML-CP patients who received imatinib treatment, 2 cases with the shorter telomere occurred transformation to BP in less than 6 months, the other 3 cases obtained CHR within 3 months, CCyR at 6 months and no transformation to BP was observed in our follow-up of 10 months.14 AL patients who undergone simultaneous analysis of TL and immunophenotype show the coincidence with the convention immunology in cell differentiation antigen expression. TL combined with cell differentiation antigen of 5 cases were dynamically detected at different courses of disease. It showed that TL of 2 cases with continued CR restored after CR and remained at normal level during remission, and no specific antigen expressed highly. However, telomere of 3 relapsed cases were significantly shortened at impetus stage, prolonged after CR and shortened again after relapse. In 2 relapsed cases, the telomere of related antigen positive cells shortened before the whole cells, and ahead of cell morphology change.Conclusions:The TL was significantly shorter in 34 de novo leukemia patients than in normal controls except the CML-CP cases. Restored telomeres were found with clinical remissions in 14 AL cases. The two methods of FLOW-FISH and RQ-PCR generated the same results and showed notable correlated.There was a significant negative correlation between TL and age in normal controls, and the female had longer telomere than the male. However no statistic difference between TL and age or gender existed in de novo leukemia patients. The TL of 24 AL cases had a negative correlation with peripheral white cells counts. It seemed the shorter telomere mean the lower CR rates in 23 follow-up cases with AL and the shorter duration of CP before onset of BP in 5 cases with CML.Simultaneous analysis of TL and cell differentiation antigen by multicolor FLOW-FISH made for overall monitor for leukemia and might be a new generally applied method for monitoring MRD in leukemia.

A Method to Identify Patients with Multiple Myeloma Who Are at Risk of Developing Concomitant Amyloidosis

INTRODUCTION : Multiple myeloma (MM) is a plasma cell dyscrasia that is characterized by the presence of both a clonal plasma cell population in the bone marrow and intact monoclonal immunoglobulin and/or free light chain (LC) proteins in the serum. It has been shown that MM may be an ominous precursor to light chain-associated (AL) amyloidosis, a devastating protein misfolding disorder characterized by the systemic deposition of extracellular amyloid fibrils composed of LC components. In the US, there are ~30,000 new cases of MM every year, and it is estimated that 10 - 15% of these patients will progress to develop amyloidosis.Light chain amyloid may deposit in any organ or tissue, but the heart, liver, spleen, kidneys and nerves are most commonly involved. The accumulation of amyloid in organs, especially the heart and kidneys, results in architectural damage leading to progressive organ dysfunction and death. It has been documented that concomitant MM with amyloidosis results in a considerably poorer prognosis than MM alone.Currently, there is no way of identifying those MM patients who will progress to develop LC-associated amyloidosis, but the ability to identify at-risk patients would be of clinical value because anti-amyloid immunotherapeutic agents are on the horizon. If such patients are identified prior to the onset of amyloid-associated clinical symptoms and organ damage, physicians could implement closer monitoring and begin a maintenance dose of amyloid-clearing antibody reagents.Early detection of amyloid is critical for enhancing patient survival; thus, we have investigated an approach to discern which MM patients have a greater likelihood of developing amyloidosis, based on the amyloid-related properties of the monoclonal light chain. We have previously shown that LC derived from MM and AL patients, when radiolabeled, can be recruited by synthetic amyloid-like fibrils. We observed that MM LC were recruited less effectively than AL LC, suggesting that there is disease specific reactivity of LC with amyloid fibrils (Martin et al . 2017 PLoS One, 12(3): e0174152.). We have since adapted this approach to a more facile and practical microplate assay measuring the ability of LC to compete with monomeric protein for fibril elongation. We have been able to discern patient populations with this technique.MATERIALS & METHODS : For these studies, 96-well microplates were coated with 0.83 μM synthetic amyloid-like fibrils (rVλ6Wil) and dried at 37°C overnight. After washing and a “blocking” step, a 100 μL solution of urinary LC protein-either AL amyloidosis or MM patient-derived-at increasing serial concentrations (0.05 - 5 µg/mL) mixed with biotinylated rVλ6Wil protein monomer (5 nM) was added to the wells. After 1 h incubation, the amount of fibril-recruited biontinyl-rVλ6Wil monomer was measured. Concentration gradients for MM and AL LC were measured and compared using a one-tailed Student's t-test.RESULTS : The data indicate that, in this competition assay, AL-associated urinary LC inhibited rVλ6Wil monomer recruitment more effectively than MM-derived LC. Our concentration-dependent gradient analysis discerned proteins from the two disease populations with statistical significance (p < 0.007). Notably, LC from a patient initially diagnosed with MM, who later developed amyloidosis, behaved as an AL LC in this assay, indicating the ability of this technique to predict the amyloidogenic propensity of LC.DISCUSSION : We have studied the capacity of intact, patient-derived LC to inhibit synthetic fibril elongation as a means of predicting the risk of amyloidosis. The assay was able to discriminate between LC proteins derived from MM and AL patients. This approach, in conjunction with other metrics, may be useful in discerning those patients with MM, or perhaps LC-associated monoclonal gammopathy of undetermined significance (LCMGUS), who are at risk of developing amyloidosis based on LC activity in our recruitment assay. We are currently adapting this technique for use with patient serum. [Display omitted] DisclosuresMartin:University of Tennessee Research Foundation: Patents & Royalties. Wall:University of Tennessee Research Foundation: Patents & Royalties.

Fbxw11 Triggers a Dual Signaling Axis to Exert Proliferation Effects on Lymphocytic Leukemia

Dysregulation of signal conduction will break the balance of normal hematopoiesis and cause various blood diseases. Ubiquitin-proteasome system (UPS) takes part in both physiological and pathological processes by post-translational regulating intracellular signal transduction pathways. Fbxw11 as a constituent of the SCF (Skp1-Cul1-F box) E3 ubiquitin ligase complex, regulates various signal transduction pathways and its pathological roles in tumorigenesis have been suggested. However the role of Fbxw11 in the development of leukemia and the underlying mechanisms remain largely unknown.To assess the clinical relevance of Fbxw11, the expression of Fbxw11 in AL patients was also studied by real-time PCR. The expression of Fbxw11 was higher in newly diagnosed ALL (p=0.0304) and relapsed ALL patients (p=0.0389) than that in healthy donors. However, results from a follow-up study demonstrated that the expression of Fbxw11 was dramatically decreased after chemotherapy achieving CR (p=0.0202). These results were conformed in the BloodSpot database.To study in vitro effects of Fbxw11 on leukemia cells, the lymphocytic leukemia cell line, L1210, was stably transfected with Fbxw11 transcript variants and defined as L1210-control, L1210-Fbxw11a, L1210-Fbxw11c and L1210-Fbxw11d, respectively. Increased percentage of S/G2/M phase cells was detected in L1210 cells with high level Fbxw11 by PI stainingand Ki-67/hoechst33342 staining. Fbxw11 significantly promoted the growth of L1210 cells. The proliferation effects of Fbxw11 on the leukemia cells were also tested in vivo . Tumor growth was significantly higher in groups with high level Fbxw11 variants. Significantly higher rate of Brdu positive cells were detected by confocal microscopy in slides formed by L1210 cells expressing high level Fbxw11 variants than control slides .To further investigate the pro-proliferation mechanism by Fbxw11 transcript variants, Agilent Sureprint G3 Mouse Gene Expression Microarray was performed after total RNA was isolated from control L1210 cells and those expressing high level Fbxw11 transcript variants. Categories of NF-κB and Wnt/β-catenin signaling pathway has high enrichment score in KEGG and IPA respectively. Categories of regulation of cell proliferation and positive regulation of T cell proliferation have high enrichment score in GO biological process. Cell cycle regulator, CyclinD1 and CyclinD3, which were regulated by multiple transcription factors including NF-κB and β-catenin, were significantly up-regulated in L1210 cells expressing high level Fbxw11 transcript variants at protein level. The expression of other NF-κB-regulated genes and β-catenin/TCF-regulated genes were also up-regulated in L1210 cells with high level Fbxw11 transcript variants, which was consistent with the array data. Activation of both NF-κB and β-catenin/TCF signaling pathways was detected in 293T cells expressing high level Fbxw11 transcript variants by dual luciferase reporter system. Furthermore, combination of low dose inhibitors for NF-κB and β-catenin/TCF pathways (ICG-001 and JSH-23) completely diminished pro-proliferation effects of Fbxw11 though the use of low dose either inhibitor had little effect.Taken together, Fbxw11 was up-regulated in ALL patients. High level expression of Fbxw11 stimulated the proliferation of L1210 lymphocytic leukemia cells in vitro and promoted tumor formation in vivo through cell cycle regulation. Most importantly, activation of both NF-κB and β-catenin/TCF signaling pathways were involved in this process. This work highlights dual signaling activation and illustrates the mechanism of Fbxw11 on the development of lymphocytic leukemia and implys possible approaches for leukemia therapy.The work was supported by the Grants 81300376, 81370634, 81570153, from the National Natural Science Foundation of China (NSFC); 14JCQNJC10600 and 17 JCZDJC35000 from the Tianjin Science and Technology Programs DisclosuresNo relevant conflicts of interest to declare.

Daratumumab Activity Is Agnostic to Fc Gamma Receptor 3A (FcγR3A) 158 Genotype in Patients with Primary Refractory or Relapsed Systemic AL Amyloidosis

Introduction: Treatment targeted at the clonal plasma cells that produce the pathologic immunoglobulin light chain in patients with systemic AL amyloidosis, if effective and timely, can normalize serum free light chains resulting in organ responses and significantly improved overall survival. A third of patients with AL have no response to initial therapy, and over half of those who respond to initial therapy will relapse in 4 years; non-responders and relapsed patients with cardiac involvement are at especially high risk of shortened survival. Single agent daratumumab has been shown to have a response rate of 36% in relapsed refractory multiple myeloma patients (Lokhorst, Plesner et al. 2015). Daratumumab is an option for patients with AL who have marrow plasma cell burden > 10%, consistent with myeloma. Antibody- dependent cellular cytotoxicity is a mechanism of action of daratumumab, and this implicates recognition of the FC portion of the therapeutic antibody by FC receptors on effector cells such as macrophages and NK cells. A single nucleotide polymorphism at codon 158 of the FcγR3A receptor has been shown to affect the therapeutic efficacy of monoclonal antibodies(Mellor, Brown et al. 2013). The aim of this study was to assess hematologic and organ responses to daratumumab in a cohort of AL patients with primary refractory or relapsed clonal plasma cell disease and to test whether FcγR3A genotype influenced response to daratumumab.Materials and Methods: Patients with biopsy proven AL amyloidosis and organ involvement evaluated at Tufts Medical Center who received daratumumab were identified and evaluated for hematologic and organ responses according to consensus criteria (Comenzo, Reece et al. 2012, Palladini, Hegenbart et al. 2014). FcγR3a genotype for each patient was identified by PCR amplification and sequencing using genomic DNA from blood or marrow mononuclear cells. The translation of 158F or 158V in the alleles of the membrane-proximal extracellular domain was determined by T/G zygosity at nt559 in the gene sequence.Results: Fifteen patients with AL amyloidosis (λ=10, κ=5) who had primary refractory (no response after at least 2 cycles of initial therapy) (n = 5) or relapsed clonal plasma cell disease (n = 10) received daratumumab at standard doses at a median of 29 months from diagnosis (range, 2-107). Median age at diagnosis was 62 years (47-73) and 60% were male. The median lines of prior therapy were 3 (1-5). Eighty seven percent (n=13) had received bortezomib-based therapy and 53% (n=8) had undergone high-dose melphalan with autologous stem cell transplant. Nine patients had renal involvement (6 with stage 3), and 9 had cardiac involvement with a median NT-proBNP of 2373pg/ml (553-18021). All patients are alive with a median follow-up of 7 months (1-16). Hematologic responses were seen in 87% (CR=5, VPGR=8) with a median time to best response of 71 days. Forty four percent (n=4) had a renal response within an average of 107 days while 55% (n=5) achieved a cardiac response within an average of 149 days. Responses did not correlate with FcγR3A genotype (see figure below). Those with 158V/V or V/F had 3 CR, 3 VGPR and 1 no response (NR) while those with 158F/F had 2 CR, 5 VGPR and 1 NR. The ratio of FcγR3A 158 genotypes in patients with systemic AL amyloidosis has not previously been studied.Conclusions: Daratumumab achieved rapid hematologic responses in over 85% of patients with primary refractory or relapsed systemic AL amyloidosis with significant organ responses. Daratumumab activity was agnostic to FcγR3A 158 genotypes in this cohort of patients, in whom, of note, the distribution of genotypes is of interest. The basis for daratumumab activity may be linked to other mechanisms such as direct cytotoxicity or to the low fraction of cells in S-phase in AL plasma cell clones (Gertz, Kyle et al. 1989). Daratumumab is a very active agent in AL and its rapid clinical evaluation in patients with newly diagnosed AL is anticipated. [Display omitted] DisclosuresComenzo:Prothena: Consultancy, Research Funding; Janssen: Consultancy, Research Funding; Karyopharm: Research Funding; Takeda: Research Funding.

What Does AL Amyloidosis Look like in the Era of Mass Spectrometry Typing?

Background: Amyloidosis can stem from various amyloid types. Accurate amyloid typing is crucial for management and prognostic purposes. Typing used to rely on immunohistochemistry and immunofluorescence methods, but is subject to considerable false positive and false negative results as well as dependence on laboratory expertise. Mass spectrometry (MS) has emerged in the past years as the gold-standard typing method with sensitivity and specificity approaching 100%. It is helpful in elimination of cases where monoclonal protein studies are an incidental finding, while amyloidosis type is in fact non-AL. With this technique in clinical practice for nearly a decade, accurate description of AL amyloidosis from a clinical and laboratory data is now feasible, which allows a refinement of the presenting features of the disease compared to prior cohort descriptions.Methods: Five hundred and ninety two patients with biopsy-proven, MS confirmed AL amyloidosis diagnosed between 2008 to 2015 are included. Monoclonal protein studies were performed at diagnosis before treatment initiation and included: serum immunofixation (IFE), urine IFE and serum free light chain assay (sFLC). Comparison was made with data from prior study pre-MS era from our institution: (Gertz MA, Kyle RA. (1989) Primary systemic amyloidosis: a diagnostic primer, Mayo Clinic Proceedings).Results: A lambda clone was seen in 75% of patients in the MS-verified cohort, compared to 62% in the prior study. The rate of detection of a monoclonal protein by serum or urine IFE was 94%, as compared to 86% previously (Figure). The distribution of monoclonal proteins also differed with more patients in the earlier cohort with an IgG kappa and fewer without an intact immunoglobulin. Abnormal sFLC ratio (>1.65 or <0.26) was detected in 91% of patients in the current series, while 78% of patients had ratio >3.3 or <0.13. Overall, the median difference between involved to uninvolved light chains (dFLC) was 25 (11-65) mg/dL. Two patients had a negative dFLC (-0.7 & -5.7 mg/dL; both lambda type), while 13 patients (2%) had dFLC of less than 1 mg/dL. In the current MS-verified cohort, among the 557 patients with all monoclonal studies available (SIFE, UIFE, sFLC), only one patient (0.2%) had normal monoclonal protein studies. Greater than 10% bone marrow plasma cells were seen in 35% of patients in the MS-verified cohort versus only 25% in prior earlier cohort who had this degree of bone marrow involvement. Other differences between the two groups were male gender (64% versus 61%), frequency of cardiac involvement (76% versus 40.5%) and frequency of nerve involvement (26% versus 19%). Frequencies of renal (53% vs 48%) and liver involvement (18% vs 16%) were similar between studies.Conclusion: When mass spectrometry is used to definitively type amyloid and state of the art serum and urine immunofixation and serum free light chain analysis are used, only a fraction of a percent of AL patients have negative monoclonal protein studies, unlike historical reports. Whether this is due to a drift in the prevalence of monoclonal proteins over time or a reflection of misclassification in an era with limited diagnostic capability will require further study. [Display omitted] DisclosuresGertz:Millennium: Consultancy, Honoraria; Celgene, Novartis, Smith-Kline, Prothena, Ionis, Amgen: Honoraria. Dingli:Millenium: Consultancy; Alexion Pharmaceuticals: Consultancy; Janssen: Consultancy; Takeda: Consultancy; Karyopharm Therapeutics: Research Funding. Kapoor:Takeda, Celgene and Amgen: Research Funding. Russell:Vyriad: Equity Ownership; Imanis Life Sciences: Equity Ownership. Kumar:Celgene, Millennium, BMS, Onyx, Janssen, Noxxon, AbbVie, Amgen, Merck, Oncopeptides, Skyline Diagnostics, Takeda: Consultancy; Celgene, Millennium/Takeda, Onyx, AbbVie, Janssen, Sanofi, Novartis, Amgen, Genentech, Merck, Oncopeptides, Roche, Skyline Diagnostics: Research Funding; Skyline: Honoraria. Dispenzieri:Celgene, Millenium, Pfizer, Janssen: Research Funding.

Minimal Residual Disease (MRD) Assessed By Flow Cytometry in Patients with AL Amyloidosis Treated with Cyclophosphamide, Bortezomib and Dexamethasone (CyBorD)

Introduction In the field of multiple myeloma (MM), the clinical utility of minimal residual disease (MRD) has been an area of extensive research. The use of MRD assessment in AL amyloid patients is an emerging area of interest. In the present study, we aimed to describe the rate of MRD negativity for patients treated with CyBorD at our Institution. Methods All consecutive AL amyloid patients treated with CyBorD at Tom Baker Cancer Center from 01/13 to 04/17 were evaluated. MRD was assessed by multiparameter flow cytometry as per Euroflow consensus guidelines in patients with confirmed complete response. A p value of <0.05 was considered significant. Survival curves were constructed according to the Kaplan-Meier method and compared using the log rank test. Results 41 consecutive patients with newly diagnosed (n=35) and relapsed AL (n=6) who had received CyBorD at our Institution over the defined period were evaluated. 5 patients were excluded due to lack of follow-up or enrolment in clinical trials. Clinical characteristics are shown in Table 1 for the remaining cases (n=36). CyBorD was administered with bortezomib at 1.3-1.5 mg/m2 SC or IV for 3-4 weeks on a weekly basis in 34 cases and biweekly in 2 patients, cyclophosphamide was given at 300 mg/m2 on days 1, 8, 15 and 22 and dexamethasone at 20-40 mg/PO on days 1, 8, 15 and 22. After a median of 5 cycles, ORR was seen in 91.6% of cases with a PR of 36.1%, VGPR of 27.8% and CR of 27.8%. MRD negativity was observed in 5/10 cases with complete response. MRD negativity rate of 13.8% was reported for the whole group of patients. Organ and cardiac responses were observed in 36.1% and 27.3%, respectively. Median OS was similar between MRD positive and negative cases (NR vs NR, p=0.1) (Fig 1a). However, none of the MRD negative cases has died or progressed. A trend towards better PFS was observed in the MRD negative cases (p=0.06) (Fig1b). In conclusion, MRD negativity was observed in ~15% cases of AL patients treated with CyBorD after a median of 5 cycles. Further studies to assess the impact of MRD negativity on clinical outcomes and its role for guided therapy are required. [Display omitted] DisclosuresJimenez-Zepeda:Takeda: Honoraria; Janssen: Honoraria; Celgene: Honoraria; Amgen: Honoraria. Neri:Celgene: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria, Research Funding. Bahlis:Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Composite Organ and Hematologic Response Model Risk Stratifies Patients with Light Chain Amyloidosis

Composite Organ and Hematologic Response Model Risk Stratifies Patients with Light Chain Amyloidosis

Epidemiology of AL Amyloidosis in a US Commercially Insured Population

Introduction: Amyloid light chain (AL) amyloidosis is a rare, progressive, and typically fatal disease caused by extracellular deposition of misfolded immunoglobulin light chains. There is a paucity of epidemiological studies of AL amyloidosis, and many existing studies are not recent. The objective of the current study was to provide an up-to-date estimate of the prevalence and incidence of AL amyloidosis in the US.Methods: This was a retrospective, cross-sectional study using 2007-2015 data from the Truven MarketScan® Commercial and Medicare Supplemental claims databases. As there is no diagnosis code specific to AL amyloidosis, the following algorithm was used to identify patients. Adults ≥18 years old with AL amyloidosis were identified if they (1) had at least one inpatient claim or two outpatient claims consistent with AL amyloidosis [International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes: 277.30 or 277.39; International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes: E85.4x, E85.8x, or E85.9x] in any diagnosis field within each calendar year and (2) received one AL-specific treatment (eg, chemotherapy, hematopoietic stem cell transplant [HSCT]) on or after the first amyloidosis diagnosis in the study period. Prevalence was calculated as the number of AL patients divided by the number of enrollees on June 30 of each calendar year and reported as per million person-years (PMPY). Incidence was calculated as the number of patients with AL amyloidosis who were disease free and enrolled in a health plan for 1 year prior, divided by the number of enrollees enrolled from July 1 of the previous year to June 30 of each calendar year and reported as PMPY. A sensitivity analysis requiring enrollees to have continuous enrollment in each calendar year (and in the year prior for incident cases) found similar estimates.Results: Between 2007 and 2015, 7,326 prevalent patients with AL amyloidosis were identified, ranging from 368 to 1,080 cases per year. The mean (SD) age of prevalent cases was 63 (12) years and was stable from 2007 to 2015. The prevalence of AL amyloidosis increased significantly during the study period: from 15.5 in 2007 to 40.5 cases PMPY in 2015, an annual percentage change (APC) of 12% (P < 0.001) (Figure 1). The incidence of AL amlydoisis ranged from 9.7 to 14.0 cases PMPY, with no statistically significant increase (APC:3.1%; P= 0.114) (Figure 2). Prevalence and incidence were generally higher in males than females.Conclusion: The pattern of an increase in AL amyloidosis prevalence, coupled with stable incidence, is consistent with earlier diagnosis over time that extends life, although our study could not determine whether this mechanism was responsible for the observed change. Our database included commercially insured patients only and so may not precisely reflect the US population. Cases were identified using claims, not clinical methods, which might overestimate or underestimate prevalence and incidence. Nonetheless, extrapolating from these data, there are at least 12,000 adults in the US currently living with AL amyloidosis, and the number seems likely to rise in the future. [Display omitted] DisclosuresQuock:Prothena Biosciences Inc: Employment, Other: Stockholder. Yan:Partnership for Health Analytic Research, LLC: Employment. Chang:Partnership for Health Analytic Research, LLC: Employment. Broder:Partnership for Health Analytic Research, LLC: Employment.

Bortezomib-Maintenance for Patients with AL Amyloidosis: A Single Center Experience

Introduction AL amyloidosis is a clonal plasma cell disorder characterized by the deposition of monoclonal light-chain fibrils into extracellular tissues, leading to organ dysfunction. Data on maintenance in AL amyloidosis is scarce and only a small study with high-dose dexamethasone followed by maintenance dexamethasone/interferon is available in the medical literature. Based on the above mentioned, we aimed to explore the role of bortezomib maintenance for the treatment of AL amyloidosis. Methods All consecutive AL amyloid patients treated at Tom Baker Cancer Center with bortezomib-containing regimens (BCR) from 01/09 to 03/17 were evaluated. A p value of <0.05 was considered significant. Survival curves were constructed according to the Kaplan-Meier method and compared using the log rank test. All statistical analyses were performed by using the SPSS 24.0 software. Results 63 consecutive patients with AL who had received BCR at our Institution over the defined period were evaluated. Clinical characteristics are shown in Table 1. 19 patients had received maintenance bortezomib (bortezomib 1.3-1.5 mg/m2 every other week) and 10 out of these 19 received more than 12 months of therapy. Median bortezomib dose on the maintenance group was 42.9 mg/m2 compared to 15.6 mg/m2 in the no-maintenance group (p=0.03). At the time of analysis, 43 patients are still alive and 14 have already progressed. No differences with regards to best response rates were seen between the maintenance and no-maintenance groups (VGPR/CR rate of 68.4% vs 63.6%, p=0.2). Further, overall survival was similar between patients receiving or not bortezomib maintenance (NR vs 72 months, p=0.6) However, a trend towards better PFS was observed for the group receiving maintenance (65 vs 37 months, p=0.3) (Fig 1) In conclusion, BCR are efficacious for the treatment of AL amyloidosis. The present study reports on the use of bortezomib maintenance for the treatment of AL patients. Our study failed to identify a significant benefit on response rates or survival but further investigation is needed to assess whether a subgroup of patients might benefit from this strategy, especially now that novel tools of monitoring such as Minimal Residual Disease assessment are investigated. [Display omitted] DisclosuresJimenez-Zepeda:Celgene: Honoraria; Takeda: Honoraria; Amgen: Honoraria; Janssen: Honoraria. Neri:Janssen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding. Bahlis:Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Amgen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

Impact of early response on outcomes in AL amyloidosis following treatment with frontline Bortezomib

The outcomes in systemic AL amyloidosis are dependent on the depth of haematologic response. However, there is limited data on the impact of the speed of response on outcomes. Here we report the impact of speed of response in a cohort of AL patients treated with upfront Bortezomib. Patients seen from February 2010 until August 2019 are included in the present analysis. 1194 & 1133 patients comprised the ITT and 1-month landmark cohorts. In the landmark cohort, 137 (11.5%), 270 (22.6%), 252 (21.1%) and 352 (31.1%) patients had a CR, VGPR, PR and NR at 1-month. Patients with ≥ VGPR at 1-month had significantly better survival (median not reached; at the end of 1, 2, 5,10 years, 87%/92%, 83%/87%, 68%/72% and 63%/58% of patients in CR/VGPR, respectively, were alive) compared to those with a PR (median OS 60 months) or NR (median OS 32 months) (p < 0.005). At 1-month, patients with CR and iFLC < 20 mg/l had a significantly better survival compared to CR and iFLC > 20 mg/l (p = 0.005). Reaching ≥ VGPR at 1-month significantly improved survival in all Mayo disease stages. In conclusion, patients achieving an early deep haematologic response have a significantly superior survival irrespective of cardiac involvement.

First results from a randomized phase II study of cabazitaxel (CBZ) versus an androgen receptor targeted agent (ARTA) in patients with poor-prognosis castration-resistant prostate cancer (mCRPC).

5059 Background: In the OSTRICh trial, poor-prognosis mCRPC patients were randomized between CBZ and ARTA, following progression on docetaxel (DOC) treatment. Methods: The OSTRICh trial is an open label, multicenter, phase IIb study. Patients with poor-prognosis mCRPC (visceral metastases AND/OR &lt; 12 months responsive to androgen deprivation AND/OR progressing during or within 6 months after DOC completion), were randomized 1:1 between CBZ (25 mg/m2 IV Q3W and prednisone 2 d 5 mg PO) and ARTA (daily abiraterone 1000 mg and prednisone 2 d 5 mg PO OR enzalutamide 160 mg PO). Life prolonging therapy between DOC and randomization was not allowed. Primary endpoint was to establish the Clinical Benefit Rate (no radiotherapy, no ECOG PS increase ≥2, no change of therapy AND no radiological progression) at 12 weeks (CBR) in the study arms, while formal comparison of the CBR was a secondary endpoint. A Fisher Exact test was used to assess differences in rates and a log rank test to assess differences in progression free and overall survival. All time to event endpoints were estimated with the Kaplan-Meier method and censored at last follow-up. Results: A total of 106 patients were randomized, 53 in each arm. Baseline median age was 70 (IQR 67-75) years and PSA 79.4 (IQR 29.0 - 160) ng/ml. ECOG PS score was 0/1 in 99 (93%) and 2 in 7 (7%) patients. Al patients fulfilled the criteria for poor-prognosis disease. Thirty-six (34%) patients received DOC in the metastatic hormone sensitive stage, while 41 (39%) previously received ARTA. Twenty-six of 43 evaluable patients in the CBZ arm had clinical benefit at 12 weeks (CBR: 60%, 95% CI: 44%-75%) and 20 of 39 (CBR: 51%, 95% CI: 35%-68%) in the ARTA arm (p = 0.50). At 12 weeks, 30 of 34 (88%, 95% CI: 73% - 97%) patients in the CBZ arm and 24 of 36 (67%, 95% CI: 49% - 81%) patients in the ARTA arm had no radiological progression (p = 0.046). After a median follow-up of 16.4 months (95% CI: 13.6–27.8), a serum PSA decrease ≥50% from baseline was established in 12 (23%, 95% CI: 12% - 36%) and 26 (49%, 95% CI: 35% - 63%)(p = 0.008) patients treated with CBZ and ARTA, respectively. Median radiological progression free survival (rPFS) was 6.0 months (95%CI: 4.11-14.5) in the CBZ arm and 5.8 months (95% CI: 5.22-10.2) months in the ARTA arm (p = 0.5), while median overall survival (OS) was 15.3 months (95%CI 9.49-22.4) and 13.8 months (95%CI 11.7-16.4) in CBZ and ARTA treated patients, respectively (p = 0.8). Grade ≥3 adverse events (AEs) occurred in 15 (29%) and 8 (15%) of patients treated with CBZ and ARTA, respectively. Conclusions: No significant difference in CBR was established between CBZ and ARTA treated patients. However, at 12 weeks significantly more CBZ treated patients had no radiological progression, while ≥50% PSA response rates were higher in ARTA treated patients. Clinical trial information: NCT03295565.

Second Stem Cell Transplantation for Relapsed Refractory Light Chain (AL) Amyloidosis

Autologous stem cell transplantation (ASCT) is an effective treatment modality in light chain (AL) amyloidosis but can be offered only to a subset of patients. The feasibility, benefit, and risks of second ASCT (ASCT2) have been rarely reported. The objective of this study was to assess the utility of ASCT2 in AL amyloidosis and to identify the target population with the greatest benefit. This retrospective study examined all AL patients who underwent ASCT2 for relapsed refractory disease between 2003 and 2020. Twenty-six patients were included. The use of ASCT2 has increased over time, from 2.5% of all ASCTs from 2003 to 2011 to 5% from 2012 to 2020 (P = .056). The median time between the first ASCT (ASCT1) and ASCT2 was 7.2 years (range, 0.6 to 17.7). Fifty-four percent of patients received at least one line of therapy between ASCTs. Second stem cell mobilization prior to ASCT2 was required in 42% of patients. Full-dose melphalan (200 mg/m2) was given to 73% of patients. Two patients had failed to engraft by day 100 but eventually recovered to normal blood counts. Both had second stem cell mobilization prior to ASCT2 with prior melphalan exposure. Four patients (15%) died before day 100. Progression-free and overall survival were significantly longer from ASCT2 for those who had durable remission after ASCT1 (≥5 years) and for those who did not receive therapy between ASCTs. ASCT2 is feasible and can produce favorable outcomes, especially among those with durable response to ASCT1. ASCT2, if chosen, should preferably be performed after durable response to ASCT1 and at first progression.