Monoclonal Gammopathy Of Unknown Significance Patients Research Articles

Levels of Individual Mid and Long Chain Polyunsaturated Triacylglycerols (TAGs) Are Different between the Bone Marrow Microenvironment of Patients with Multiple Myeloma (MM) and Monoclonal Gammopathy of Unknown Significance (MGUS)

Background: It has been recently demonstrated that altered lipid metabolism involving increased free fatty acids (FFAs) uptake supports the growth and proliferation of MM cells (Panaroni et al. Blood 2022; Farell et al. Elife 2023). Whether the availability of FFAs in the bone marrow (BM) microenvironment is associated with the pathogenesis of MM from MGUS has not been previously evaluated. Thus, we evaluated if individual species of FAs or FA-containing lipids such as triacylglycerols (TAGs), diacylglycerols (DAGs), and monoacylglycerols (MAGs) are differentially present between the BM microenvironment of MGUS and MM patients. Methods: Lipid profiles of BM plasma samples (reflective of the BM microenvironment) from patients with a spectrum of plasma cell disorders (22 MGUS and 24 MM (15 newly diagnosed and 9 relapsed/refractory)) were acquired by liquid chromatography (LC)/tandem mass spectrometry (MS), and individual lipid species were quantified based on single-point quantification using 55 isotopically labeled internal standards. Concentration-based lipid species data was analyzed by the web-based tool MetaboAnalyst 5.0. Data was normalized by quantile normalization, log transformed and scaled by Pareto scaling. p values <0.05 were considered significant. Results: A total of 993 distinct lipid species were quantified by the MS-based targeted lipidomics assessment. Of these lipid species, the levels of individual mid-chain (≤50 carbon chain length) and long-chain (≥52 carbon chain length) polyunsaturated TAGs were the most differentially present in the BM plasma of MM compared to MGUS patients (Figure 1A). Even though a principal component analysis (PCA) involving all lipid species showed moderate separation of MM from MGUS patients, five MGUS patients (categorized as MGUS-other (MGO)) who clustered more towards MM patients compared to the remaining MGUS patients had a distinct pattern of individual mid and long-chain polyunsaturated TAG levels that were comparable to MM patients (Figure 1B). Furthermore, the proliferation rate of clonal plasma cells in the BM of these MM and MGUS as measured by the S-phase% was found to be directly correlated with the level of long-chain polyunsaturated TAGs. Conclusions: Mid and long-chain polyunsaturated TAGs are present in lower and higher levels, respectively, in the BM microenvironment of MM compared to MGUS patients. These findings continue to support the importance of FA-containing TAGs and other lipids in the pathogenesis of MM. Future confirmatory studies evaluating the biological significance of these differences are required to determine if they can be exploited for diagnostic and therapeutic purposes.

A Risk Model to Predict the Longitudinal Decline in Creatinine Clearance Among Patients with Precursor Plasma Cell Dyscrasia with Baseline Chronic Kidney Failure

Monoclonal Gammopathy of Unknown Significance (MGUS) is characterized as an age-dependent condition that presents with circulating monoclonal protein originating from the clonal proliferation of plasma cells in bone marrow without overt renal failure. However, these proteins have potentials to exert stress on Glomeruli, proximal or distal tubular cells through activation of TOLL-like receptors resulted from excessive endocytosis of light chain proteins, leading to subclinical renal pathologies. This phenomenon lead to forming a new clinicopathological entity named Monoclonal Gammopathy of Renal Significance (MGRS) and can be more pronounced in patients with marginal renal function due to other causes. Importantly, the establishment of MGRS diagnosis is based on renal biopsy which is avoided frequently due to its invasive nature, therefore its overall incidence remains to be defined. Here we aim to define a risk model to predict the rate of worsening renal function in patients with Chronic Kidney Disease (CKD) who have simultaneous MGUS. Methods: To define the impact of circulating monoclonal protein on natural course of CKD progression we conducted a retrospective study of CKD patients with MGUS vs. CKD patients without MGUS. Primary end point of the study was Time to End Stage Renal Disease (TTESRD) measured from the date of diagnosis of CKD to the date of diagnosis of ESRD and was censored at the date of last follow-up for those without ESRD with death as competing risk. The Fine and Gray method was used for comparisons of cumulative incidence of ESRD between groups. The effect of important factors on TTESRD was further evaluated using multivariable Fine and Gray method. Survivor distribution was estimated using Kaplan-Meier methods and the difference of OS between/among groups was examined by log-rank test. The difference of continuous variable (age) between group was examined using T-test and the association between two categorical variables was examined using Chi-square test. CKD stages is defined by Glomerular Filtration Rate (GFR) into classic 5 categories as explained before. The rate of stage progression was analyzed as secondary end point. Results: Patients without valid data (age, date of diagnosis, invalid follow-up data) were excluded for the statistical analysis. The final analysis set included 626 patients with MGUS and CKD and 15337 patients with CKD but without known MGUS. The median follow up time was 19.7 months (range: 0.03, 128). The distribution of CKD stage and other risk factors at both cohorts are illustrated in Table-1. There was significant difference of time-to-ESRD comparing the patients who had CKD alone to patients who had both CKD and MGUS (p = 0.037) in the univariate analysis. After controlling the effects of age, gender, race, CKD stage, diabetes and hypertension, there was still marginally significant difference of TTESRD, comparing the patients who had CKD alone to patients who had both CKD and MGUS (p = 0.056). Specifically, the hazard of having ESRD for patients who had CKD without MGUS was 1.64 times (95% CI: 0.99, 2.72) of the hazard of having ESRD for patients who had CKD and MGUS (see Figure-1). The CKD stage advancement according to MGUS was analyzes as the secondary end-point of the study. The CKD stage at baseline was compared to the CKD stage at year 1 and year 5 during follow-up. The progression by stage was 28.5% at year 1 for patients without MGUS vs. 29.3% for those with MGUS (p = 0.73). The progression by stage was 38.7% at year 5 for patients without MGUS vs. 39.4 % for those with MGUS (p = 0.89).There was no statistically significant difference between median OS for CKD patients with or without MGUS. Conclusion: Here we presented the data of around 16,000 CKD pts based on the MGUS diagnosis in 19 years time span and we could not detect any higher trend for CKD pts with MGUS to develop ESRD or move to higher CKD stage. These data can suggest MGRS forms a quite thin slice of the whole MGUS population. Assessing finding of this study in a larger national database is warranted. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Immune cell differences between patients in different stages of monoclonal plasma cell disorders.

8065 Background: Multiple myeloma (MM) is an incurable plasma cell malignancy. Precursor conditions include monoclonal gammopathy of unknown significance (MGUS) and smoldering multiple myeloma (SMM). Immune surveillance is paramount for keeping the malignancy in check, whereas a dysfunctional immune system is suspected to promote disease progression. Methods: We performed flow cytometric immune panel analyses including T-cell, B-cell, natural killer (NK) cell and dendritic cell (DC) subsets in MGUS, SMM, and MM patients between 2018-2021. Immune panels were analyzed on fresh peripheral blood samples drawn at diagnosis. The patient population were MGUS (n=28), SMM (n=19) and MM (n=94). Samples from MGUS and SMM patients were combined into a single group (asymptomatic) and were compared to MM patients (symptomatic). Lymphocytes were identified by CD45+ expression resolving against side-scattered light on a bivariate plot. B cell and NK cell antigen expression profiles were assessed from this lymphocyte population. T cell subsets were further determined by CD3+. The percent gated for each marker was summarized by cohort using the appropriate descriptive statistics and compared using the Mann-Whitney U exact test. Analyses were performed in SAS v9.4 (Cary, NC) using a two-sided α=0.05. Results: Compared to MGUS/SMM patients, MM patients had a significant lower proportion of naive B cells, NK cells, and cytolytic NK cells, and a significant higher proportion of cytolytic T cells at diagnosis (Table). Consistent with prior studies, we demonstrated an increase in exhaustion markers. There was a trend toward a higher population of CD8+ exhausted T cells in MM patients compared to MGUS/SMM patients. Since the follow up for this study was short, survival data is not mature. Conclusions: This study demonstrates the immune imbalance that occurs between myeloma precursor conditions and MM. There is a shift in certain cell subsets in the immune microenvironment that alters tumor immunosurveillance and tumor cell killing favoring disease progression. In data not shown, we are currently analyzing the bone marrow microenvironment and its relation to disease progression. Follow up studies could assess if therapeutic intervention could reverse the imbalance, restore homeostatic equilibrium with the goal of controlling disease long-term. [Table: see text]

Structural and Ultrastructural Analysis of the Multiple Myeloma Cell Niche and a Patient-Specific Model of Plasma Cell Dysfunction.

Multiple myeloma (MM) is a deadly, incurable malignancy in which antibody-secreting plasma cells (PCs) become neoplastic. Previous studies have shown that the PC niche plays a role cancer progression. Bone marrow (BM) cores from MM and a premalignant condition known as monoclonal gammopathy of unknown significance (MGUS) patients were analyzed with confocal and transmission electron microscopy. The BM aspirates from these patients were used to generate 3D PC cultures. These in vitro cultures were then assayed for the molecular, cellular, and ultrastructural hallmarks of dysfunctional PC at days 1 and 5. In vivo, evidence of PC endoplasmic reticulum stress was found in both MM and MGUS BM; however, evidence of PC autophagy was found only in MM BM. Analysis of in vitro cultures found that MM PC can survive and maintain a differentiated phenotype over an unprecedented 5 days, had higher levels of paraprotein production when compared to MGUS-derived cultures, and showed evidence of PC autophagy as well. Increased fibronectin deposition around PC associated with disease severity and autophagy dysregulation was also observed. 3D cultures constructed from BM aspirates from MGUS and MM patients allow for long-term culture of functional PC while maintaining their distinct morphological phenotypes.

MYC Translocations Identified By Sequencing Panel in Smoldering Multiple Myeloma Strongly Predict for Rapid Progression to Multiple Myeloma

IntroductionSmoldering Myeloma (SMM) is a heterogeneous asymptomatic stage between Monoclonal Gammopathy of Unknown Significance (MGUS) and Multiple Myeloma (MM). Risk of progression to MM is 10% in the first 5 years following diagnosis and greatly diminishes thereafter (Kyle et al NEJM 2007). Early intervention in SMM patients at high risk of progression extends survival (Mateos et al NEJM 2013). The IMWG 2014 Updated Criteria establish a subset of SMM patients who are at ultra-high risk for progression to MM within 2 years, and therefore merit treatment (Rajkumar et al Lancet Oncol 2014). Analyses of the genetic and molecular landscape of SMM to date report a near identical picture to MM, however most patients in these studies progress rapidly and are therefore not representative of the entire group. We performed a comprehensive analysis of SMM and MGUS patients to determine markers of high risk of progression that could identify patients to benefit from early treatmentMethodsMGUS not progressing after at least 10 years of follow up and SMM in which follow up data were available were extracted from the Plasma Cell Dyscrasia Biobank. A clinically applicable Custom Capture MM-specific sequencing platform was developed for detection of the most frequently mutated pathways in MM based on analysis of CoMMpass dataset. Coding exons of actionable genes, clinically relevant copy number abnormalities, and regions surrounding IgH (0.5Mb), IgK (0.1Mb), IgL (0.1Mb) and MYC loci (1.6Mb) to identify relevant structural variants (SVs) were included, with combined design 2.2Mb. 12 samples were pre-pooled before capture, and 2 captures were sequenced per lane of Illumina HiSeq4000. Paired-end 150bp reads were mapped to hg19 using BWA-MEM. Single nucleotide variants (SNVs) and small INDELs in capture regions were identified using the GenomeGPS analytic pipeline following Broad GATK variant discovery practices. Copy number variants (CNVs) were identified by patternCNV. SVs of translocations, inversions, large INDELs, and segmental duplications were called by the SnowShoes-SV algorithm developed in-house. False positive SVs, polymorphic SVs, and other artefacts were filtered out using in-house normal SV database.ResultsWe identified and sequenced 128 patients including 32 MGUS patients not progressing after 10 years. Of 96 SMM patients included 36 had not progressed to SMM after minimum follow up of 5 years, while 37 and 23 progressed to MM in less than 2 years and between 2-5 years, respectively. The genetic subtype of each patient was determined and verified by clinical FISH. Proportions in each genetic subgroup in MM and SMM/MGUS were similar, indicating that these are primary genetic lesions occurring early in MM pathogenesis. Median SMM time to progression (TTP) was 46 months. As in other series, HRD with IGH translocation, and t(4;14) predicted shorter TTP.Analysis of CoMMpass dataset found frequent MYC SV (38%) in untreated MM with higher frequency in HRD versus NHRD MM: 53% versus 28% (Misund, ASH 2016). No MYC SV were detected in MGUS cohort, SMM non-progressors at >5 years or SMM progressing between 2-5 years. By contrast, MYC SV were detected in 49% SMM that progressed within 2 years, 55% in HRD and 41% NHRD. SMM with MYC SV had a significantly shorter median TTP compared to patients without MYC SV (11.5 months vs 61 month; p<0.0001). Multivariate analysis with high risk genetic groups and biomarkers for progression (BMPCs >/=60% and FLC ratio 100) confirm MYC SV as an independent variable for progression to MM (hazard ratio=7, 95% confidence interval 3.6-13.7, p=0.00001).RAS and NFKB pathway mutations were observed with similar frequencies in MM and SMM progressing within 5 years of diagnosis, but with lower frequency in those not progressing by 5 years follow up, and were not observed in the MGUS cohort. A trend toward shorter TTP was observed in patients with RAS pathway mutations but did not reach statistical significance.ConclusionIn conclusion, we describe MYC translocations as a genetic marker of and likely cause of progression to MM that are absent in MGUS and SMM with TTP >2 years. In contrast MM and SMM early progressors (TTP <2 years) share a similar genetic landscape. Identification of MYC translocations at diagnosis of SMM predicts short TTP to MM, defining a novel ultra-high risk category that merits validation in prospective clinical trials. [Display omitted] DisclosuresKumar:Skyline: Honoraria; Celgene, Millennium/Takeda, Onyx, AbbVie, Janssen, Sanofi, Novartis, Amgen, Genentech, Merck, Oncopeptides, Roche, Skyline Diagnostics: Research Funding; Celgene, Millennium, BMS, Onyx, Janssen, Noxxon, AbbVie, Amgen, Merck, Oncopeptides, Skyline Diagnostics, Takeda: Consultancy. Dispenzieri:Celgene, Millenium, Pfizer, Janssen: Research Funding. Fonseca:Novartis: Consultancy; Merck: Consultancy; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; AMGEN: Consultancy; Celgene Corporation: Consultancy, Research Funding; Sanofi: Consultancy; Mayo Clinic & Dr Fonseca: Patents & Royalties: Prognostication of myeloma via FISH, ~$2000/year; Jansen: Consultancy; Bristol-Myers Squibb: Consultancy; Bayer: Consultancy; Pharmacyclics: Consultancy; Takeda: Consultancy. Stewart:Bristol-Myers Squibb: Consultancy; Celgene: Consultancy; Janssen: Consultancy; Roche: Consultancy; Amgen: Consultancy.

Extensive Changes of the Immune Microenvironment Are Associated with Progression from Precursor Stages to Multiple Myeloma

Extensive Changes of the Immune Microenvironment Are Associated with Progression from Precursor Stages to Multiple Myeloma

An in vitro investigation into the protective and genotoxic effects of myricetin bulk and nano forms in lymphocytes of MGUS patients and healthy individuals

The present study investigated the genoprotective and genotoxic effects of myricetin bulk (10 μM) and nano forms (20 μM) in the lymphocytes from pre-cancerous, monoclonal gammopathy of unknown significance (MGUS) patients and healthy individuals using the Comet and micronucleus assays. The study also evaluated the effect of myricetin on P53 expression levels, using the Western blot technique. Results showed that throughout the in-vitro treatment, lymphocytes from the patients group had higher levels of baseline DNA damage compared to the healthy group. Myricetin in both forms induced significant DNA damage, only at higher concentrations (>40 μM). The micronucleus assay showed a significant reduction (P < 0.01) in the frequency of micronuclei in mono-nucleated cells in the patient group treated with the nano form of myricetin at the non-toxic dose of 20 μM. There was a significant increase in both gene and protein P53 levels in lymphocytes isolated from healthy individuals and pre-cancerous patients. These results suggested a protective effect of myricetin and indicated its nutritional supplement potential for protection against cancer development among patients suffering from MGUS.

Diagnosis of haematological diseases with monoclonal gammopathy

AbstractDespite the complexity of lymphoproliferative disorders, the presence of monoclonal immunoglobulins has been providing diagnostic guidance to the haematologist for more than a century. Clinicians may be alerted for the possible presence of serum monoclonal immunoglobulins produced in excess by increased erythrocyte sedimentation rate. Thereafter the diagnosis of monoclonal gammopathy could be proven by serum protein electrophoresis followed by immunofixation to properly identify the M‐protein. In a quarter of the cases, no intact monoclonal immunoglobulin could be detected in the sera, however, free light chains produced in excess may be identified using specialized immunoassays, so called free light chain analysis.Idiopathic monoclonal gammopathy of unknown significance (MGUS) may be present in 1% of the population above age 50 and up to 10% for individuals over 80 years of age. Due to the high frequency of MGUS, between 50‐65% of all monoclonal proteins detected fall into this category and most asymptomatic patients remain undetected for many years. MGUS patients have a 1% per year chance for transformation into malignant monoclonal gammopathies. Presently, it is accepted that most multiple myeloma and amyloidosis patients have their disease developed by transformation from preexisting MGUS. Additionally, some nonmalignant hematological disease also frequently exhibit monoclonal immunoglobulin synthesis, most notably Gaucher’s disease.From the field of neoplastic hematological diseases, smouldering and symptomatic multiple myeloma as well as Waldenström’s macroglobulinaemia almost always exhibit significant amounts of serum M‐protein and/or monoclonal free light chain excess. In case of solitary plasmocytoma, primary AL amyloidosis, cryoglobulinaemia and plasma cell leukemia, the correlation with gammopathy is less strict. Monoclonal gammopathy is less common in different types of non‐Hodgkin lymphoma. Within lymphomas lymphoplasmocytic lymphoma and marginal zone lymphoma more commonly secrete monoclonal immunoglobulins, while other B‐cell lymphomas have 14% cumulative chance for specific gammopathy. In the case of B‐cell chronic lymphocytic leukemia (the most common leukemia), intact monoclonal gammopathy has a 2% appearance, while abnormal free light chains may be detected in a third of the cases. Sporadically monoclonal gammopathy may be detected in chronic myelomonocytic leukemia, refractory anaemia, large granular cell leukemia and angioimmunoblastic lymphoma. Notably, in many of these diseases, the amount of secreted monoclonal immunoglobulin and/or free light chains correlate with the tumor burden and could be used for disease monitoring, especially in indolent hematological neoplasias.

Distinctive patterns of peripheral neuropathy across the spectrum of plasma cell disorders

Many patients with plasma cell disorders suffer from peripheral neuropathy, but differential diagnosis with chronic inflammatory demyelinating polyneuropathy (CIDP) is difficult. We aimed to (1) identify factors useful for differential diagnosis between peripheral neuropathy associated with plasma cell disorders versus CIDP and (2) determine whether neuropathy presentations and severity varied across the spectrum of different plasma cell disorders. A retrospective chart review of 18 monoclonal gammopathy of unknown significance (MGUS) patients, 15 POEMS syndrome patients and 34 CIDP patients between January 2005 and December 2016 was conducted. The peripheral neuropathy associated with plasma cell disorders seemed to be more sensory oriented compared to CIDP. MGUS patients were significantly older than CIDP patients (median age 70 vs. 59, respectively, p = 0.027). POEMS syndrome patients showed significantly higher platelet count at the time of neuropathy presentation compared to CIDP (p = 0.028). Lambda type MGUS patients were associated with less severe symptoms compared to POEMS syndrome patients despite harboring lambda monoclonal gammopathy as a common denominator. Kappa type MGUS patients showed predominantly axonal type neuropathy compared to its counterpart and POEMS syndrome. Careful inspection of clinical profiles and symptoms of patients presenting with neuropathy can help to discriminate those with underlying plasma cell disorders. The phenotype of neuropathy, platelet count and age at presentation seem to be the most useful indicators.

SAT-526 Use of Trabecular Bone Score for Risk Stratification of Patients with Monoclonal Gammopathy of Unknown Significance

Background Monoclonal gammopathy of unknown significance (MGUS) is a common clinical finding, affecting greater than 3% of adults age 50 years or older. There is good epidemiological evidence that patients with MGUS suffer from significantly increased fracture risk. There are, however, no guidelines for evaluation and/or management of skeletal health in patients with MGUS. Trabecular bone score (TBS), a texture index derived from standard lumbar spine (LS) DXA images, provides information about the underlying trabecular bone microarchitecture independent of bone mineral density (BMD). We hypothesized that patients with MGUS have reduced trabecular microarchitecture that would be reflected by lower TBS, findings that might alter skeletal clinical care decisions. Methods We retrospectively identified 115 adult patients diagnosed with MGUS (cases) between 2005 and 2018 who had a LS DXA within 24 months prior to MGUS diagnosis. MGUS diagnosis was as defined by the 2003 International Myeloma Working Group criteria. A control group was identified, matched 1:1 for sex, age (±5 years) and BMI (± 2 kg/m2). Exclusion criteria included the presence of primary or metastatic bone malignancy, multiple myeloma, exposure to skeletal anti-resorptive or anabolic agents, or exposure to glucocorticoids for > 3 months. TBS analysis was performed retrospectively using TBS iNsight v3.0 software. TBS values were categorized as low (<1.20), intermediate (1.20 - 1.35) or normal (>1.35). Results Cases had a median age of 69.7 years (IQR 63.7 - 75.8; p=0.98 for cases vs. controls) and were predominantly Caucasian (96%; n=111), men (77%; n=89), and had a median BMI of 28.3 kg/m2 (25.5 - 32.4; p=0.92). BMD was performed after a median of 24 months from time of MGUS diagnosis (0 - 68 months). Cases had significantly higher incident fractures compared to controls (14 vs. 7, respectively, p<0.05). There was no difference between cases and controls with respect to TBS categorization (low 23 vs. 15%; intermediate 42 vs. 41%; normal 35 vs. 44%; p=0.22) or LS T-scores (-0.30 vs. +0.22, p=0.16). Although fractures occurred in controls with significantly lower TBS values (1.17 vs. 1.34 in controls with vs. without fracture, respectively, p <0.01), this was not the case in patients with MGUS (TBS 1.28 vs. 1.31 in cases with vs. without fractures, p=0.97). Similarly, there was no difference in LS T-scores in cases with or without fractures (0.29 vs. -0.4, respectively, p=0.3). Conclusion Despite MGUS patients having a significantly increased risk of fracture compared to age-, sex- and BMI-matched controls, neither BMD nor TBS, obtained within 2 years of MGUS diagnosis, were able to risk stratify patients. Indeed, unlike controls, patients with MGUS tend to fracture despite a normal BMD and an intermediate or normal TBS value. More advanced non-invasive measures of bone quality and finite element analysis may be needed to capture this risk.

Monoclonal gammopathies of unknown significance and smoldering myeloma: Assessment and management of the elderly patients

Monoclonal gammopathy of unknown significance (MGUS) is the most frequent plasma cell disorder that commonly affects elderly patients. Although it is an asymptomatic condition, as well as smoldering myeloma (SMM), the risk of progression to multiple myeloma requiring therapy or other B-cell disorders varies greatly for individual patients, remaining low for MGUS (1% per year), while higher and not uniform for SMM patients (10% per year). This scenario implies some special considerations regarding assessment and follow-up, especially in the elderly. In this review, we provide the updated diagnostic criteria of monoclonal gammopathies proposed by the International Myeloma Working Group (IMGW); the current recommendations for the assessment of asymptomatic plasma cell disorders, with some concerns about the need of geriatric evaluation in the elderly population, the importance of distinguishing myeloma-related symptomatology from signs or symptoms caused by multiple chronic conditions typically found in the elderly. Finally, the identification of predictor markers of progression has enabled a proposal of risk-adapted follow-up strategies in MGUS and SMM that should be implemented in clinical practice. Although the standard of care is observation for MGUS and SMM patients as well, a recent randomized trial targeting high-risk SMM showed the clinical benefit of early intervention. The change of the treatment paradigm is also very promising and feasible for elderly patients, as long as a comprehensive geriatric assessment is conducted to optimize early treatment and reach maximum benefit with minimum toxicity, in other words, to ensure a better quality of life for these patients.

Quality of life and cancer worry in a follow-up cohort of patients with asymptomatic monoclonal gammopathies.

8049Background: Monoclonal gammopathy of unknown significance (MGUS) and smoldering multiple myeloma (SMM) are monoclonal gammopathies that precede multiple myeloma (MM). Although considered asymptomatic, patients diagnosed with these conditions are at greatly increased risk of developing MM. There is currently limited to no information on quality of life (QOL) or cancer worry/anxiety burden for patients with MGUS and SMM. Methods: We implemented a longitudinal QOL and cancer-related worry assessment in an observational cohort study of MGUS and SMM patients at MD Anderson Cancer Center (expected total enrollment of N = 200). Questionnaires included the QLQ-C30 cancer QOL tool and the MY20 myeloma-specific module, as well as questions to measure cancer worry. In this preliminary data analysis, a total of 46 patients completed the baseline questionnaires (MGUS = 17; SMM = 29). Results: Overall, individuals with MGUS have a worse QOL compared to SMM patients with MGUS patients reporting a > 12 point lower Gl...

Abstract 2639: Survival prognosis of MGUS patients by clinical and risk subgroup: a result from a nationally representative prospective cohort

Abstract Introduction: Monoclonal gammopathy of unknown significance (MGUS) is a premalignant disorder preceding multiple myeloma that is present in 2.4% of the general population ages 50 years or older. MGUS can be categorized into conventional MGUS that includes IgM MGUS and non-IgM MGUS, and light chain MGUS (defined as those with abnormal free light chain ratio with complete lack of immunoglobulin heavy chain expression on immunofixation). Our objective was to investigate the prognosis of MGUS patients by clinical subgroup and risk stratification suggested by Mayo Clinic. Methods: Data is obtained from National Health and Nutrition Examination Survey (NHANES) III and NHANES 1999-2004, a nationally representative health survey with follow-up mortality data updated in December 2011. Subjects who were diagnosed with MGUS were included in the study. They were divided into three groups; IgM MGUS, non-IgM MGUS, and light chain MGUS (LC-MGUS). Median overall survival of three groups was obtained using log-rank test and age-adjusted hazard ratio for death between the groups was obtained using cox-proportional regression model. Finally, we also analyzed median survival and age adjusted hazard ratio on conventional MGUS subjects by Mayo clinic MGUS risk stratification based on risk factors of M-protein&amp;gt;1.5g/dL, non-IgG MGUS, and abnormal free light chain (FLC) ratio. Analyses were performed in R software version 3.2.2, and a P-value &amp;lt;0.05 was considered statistically significant. Results: 22,523 subjects in the cohort were screened for MGUS with serum protein electrophoresis, serum protein immunofixation, serum FLC assay, and M-protein typing. There were 483 subjects with MGUS (47 IgM-MGUS, 385 non-IgM MGUS, and 51 LC-MGUS). The median ages of total MGUS subjects, and subgroups were 70, 72.3, 69 and 73 years old, respectively. Median follow-up was 116 months. Median overall survival was 117 months for IgM MGUS, 173 months for non-IgM MGUS, and 109 months for LC-MGUS (p = 0.03). However, the age adjusted hazard ratio (aHR) did not show significant difference between the sub-groups. Likewise, median overall survival of Mayo Clinic MGUS risk group 0, 1, 2 and 3 was 185 months, 163 months, 137 months, and 76.5 months, respectively (p &amp;lt;0.001). Only high-risk group (risk of 3) showed statistically significant aHR 2.9 (95%CI 1.5∼5.6) compared with low risk group (risk of 0). Conclusion: There was no statistically significant mortality difference between MGUS subgroup. Only high-risk group defined by the Mayo Clinic MGUS risk stratification showed inferior survival and higher risk of death compared to rest of MGUS subjects. Further prospective studies are needed to validate our findings and to investigate whether early interventions for MGUS patients by clinical subgroup and risk stratification are needed rather than the current standard management of watchful-waiting. Citation Format: Hyun-Seok Kim, Jieqi Liu, Brittany L. Gladney, Neil Kothari, Noa Biran, Victor Chang, David S. Siegel. Survival prognosis of MGUS patients by clinical and risk subgroup: a result from a nationally representative prospective cohort. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2639.

Clonal architecture of CXCR4 WHIM-like mutations in Waldenström Macroglobulinaemia.

CXCR4(WHIM) somatic mutations are distinctive to Waldenström Macroglobulinaemia (WM), and impact disease presentation and treatment outcome. The clonal architecture of CXCR4(WHIM) mutations remains to be delineated. We developed highly sensitive allele-specific polymerase chain reaction (AS-PCR) assays for detecting the most common CXCR4(WHIM) mutations (CXCR4(S338X C>A and C>G) ) in WM. The AS-PCR assays detected CXCR4(S338X) mutations in WM and IgM monoclonal gammopathy of unknown significance (MGUS) patients not revealed by Sanger sequencing. By combined AS-PCR and Sanger sequencing, CXCR4(WHIM) mutations were identified in 44/102 (43%), 21/62 (34%), 2/12 (17%) and 1/20 (5%) untreated WM, previously treated WM, IgM MGUS and marginal zone lymphoma patients, respectively, but no chronic lymphocytic leukaemia, multiple myeloma, non-IgM MGUS patients or healthy donors. Cancer cell fraction analysis in WM and IgM MGUS patients showed CXCR4(S338X) mutations were primarily subclonal, with highly variable clonal distribution (median 35·1%, range 1·2-97·5%). Combined AS-PCR and Sanger sequencing revealed multiple CXCR4(WHIM) mutations in many individual WM patients, including homozygous and compound heterozygous mutations validated by deep RNA sequencing. The findings show that CXCR4(WHIM) mutations are more common in WM than previously revealed, and are primarily subclonal, supporting their acquisition after MYD88(L265P) in WM oncogenesis. The presence of multiple CXCR4(WHIM) mutations within individual WM patients may be indicative of targeted CXCR4 genomic instability.

The Contribution of Fibrocytes to the Progression of Multiple Myeloma

Background: Fibrocytes are circulating, pro-collagen expressing myeloid cells that contribute to wound healing. Emerging data implicates these cells in cancer progression. Our data supports a role for fibrocytes in the progression of multiple myeloma (MM). Methods: Peripheral blood and bone marrow samples were collected according to an IRB approved protocol (IRB Number: 09-0768). Fibrocytes were identified in the PBMC fraction by flow cytometry as CD45+, COL1A1+, and CD115-cells. These results were confirmed by counting fibrocytes after five days of culture in serum-free conditions. Statistical analysis was performed by dividing the sample set into four subgroups: Monoclonal Gammopathy of Unknown Significance (MGUS), Smoldering Myeloma (SM), treated myeloma (TrMM), and untreated or relapsed myeloma (U/RMM). Significance was determined using non-parametric methods with the Bonferroni correction for multiple group comparisons. The effects of MM cells on fibrocyte number were studied in vitro using a transwell system that co-cultured healthy donor PBMCs with MM cells from U/RMM patients. MM samples from patients with a greater than average number of circulating fibrocytes were compared with samples from patients with fewer than average. Results were reported as the fold increase in fibrocyte number compared with donor PBMCs alone. Differences in gene expression between fibrocytes from five U/RMM and five MGUS patients were assessed using a RT2Profiler PCR Custom Array (Qiagen). Fibrocytes were isolated by culturing PBMCs in serum free conditions followed by immunomagnetic bead purification. Results: Eighty-eight patient samples were analyzed. There were no differences in age, WBC count, monocyte count, hemoglobin, albumin, or creatinine. Measures of disease burden including β2M, percentage of bone marrow plasma cells, and concentration of the M-protein were consistent with the patients’ strata. U/RMM patients had an increased number of circulating fibrocytes (4.7 ± 0.6 x107 cells/L) compared with TrMM (2.8 ± 0.5 x107 cells/L), SM (2.0 ± 0.5 x107 cells/L), MGUS patients (2.0 ± 0.6 x107 cells/L), or healthy controls (0.8 ± 0.2 x107 cells/L) (p &lt; 0.05). These differences were confirmed using the cell culture techniques. Twenty-nine patients with MGUS or SM were not treated when entering the study. Seven of these developed progressive disease that required therapy. This group had a significantly greater number of circulating fibrocytes compared with the 22 patients without progression (2.4 ± 0.7 vs 1.3 ± 0.4 x 107 cells/L, p&lt;0.05). Primary MM cells were isolated from U/RMM patients with greater than average circulating fibrocytes (6.5 ± 1.2 x 107 cells/L) and those with less than average fibrocytes (1.8 ± 0.6 x 107 cells/L). The co-culture of these cells with healthy donor PBMCs increased the number of fibrocytes by 3.9 ± 0.9 fold. This increase was significantly greater using MM cells from patients with more circulating fibrocytes compared with those with less (5.4 ± 1.5 vs 2.5 ± 0.3 fold; p&lt;0.05). Twenty-eight potential mediators of this process were compiled from the literature and were assessed using bioinformatics applied to public databases. Of these, SPARC was the most promising candidate based on its differential expression in MM samples compared with normal plasma cells. Real time PCR measurement of SPARC expression in our U/RMM samples was positively correlated with the number of circulating fibrocytes (r=0.982, p=0.018). We began to explore the ability of fibrocytes to promote MM by screening these cells using a custom real time PCR array. Twenty genes were selected for analysis based on our work using murine models. Of these, SPP1 was expressed at least one log greater than any of the other 19 genes (p &lt; 0.01). Furthermore, fibrocytes from U/RMM patients had significantly greater expression of SPP1 than MGUS patients (1.82 fold, p&lt;0.05). Proposed Model: Our data support a model in which MM cells produce SPARC. This signal causes an expansion of fibrocytes. These cells, in turn, promote MM progression by expressing SPP1, a gene that can activate osteoclasts leading to a release of MM growth factors. In this way, fibrocytes can participate in a positive feedback loop leading to progression of myeloma. Disclosures No relevant conflicts of interest to declare.

Immunoglobulin-free light chain monomer-dimer patterns help to distinguish malignant from premalignant monoclonal gammopathies: a pilot study.

Multiple myeloma (MM) and AL amyloidosis (AL) are two malignant forms of monoclonal gammopathies. For the purposes of prognosis and treatment, it is important to distinguish these diseases from the premalignant forms of monoclonal gammopathies, such as monoclonal gammopathy of unknown significance (MGUS) and smoldering myeloma (SMM). Routine serum/urine tests for monoclonal protein are insufficient for differential diagnosis. Thus, invasive procedures, such as tissue aspiration or biopsy, are applied. In this study, we aimed at characterization of serum-free light chain (FLC) monomer-dimer patterns to distinguish the malignant from the premalignant forms of monoclonal gammopathies. A quantitative Western blotting was applied to estimate the FLC monomer and dimer levels in AL, MM, MGUS, and SMM patients, and in control subjects (healthy individuals and patients with AA amyloidosis). AL and MM patients displayed an abnormally increased dimerization of monoclonal FLC, accompanied by higher clonality values of FLC dimers, as compared to that of monomers. These abnormalities of FLC patterns were not observed in patients with MGUS, SMM, AA amyloidosis, and healthy individuals. Analysis of FLC patterns helped to differentiate AL and MM from MGUS and SMM, a goal difficult to achieve using routine serum tests. Also, our technique might serve as a complimentary diagnostic tool in the cases with suspected AL amyloidosis, where the diagnosis of MM is excluded, while the results of amyloid typing by routine immunohistochemical techniques are inconclusive.

Detection of MYD88 L265P in peripheral blood of patients with Waldenström’s Macroglobulinemia and IgM monoclonal gammopathy of undetermined significance

MYD88 L265P is highly prevalent in Waldenstrom's Macroglobulinemia (WM) and IgM monoclonal gammopathy of unknown significance (MGUS). We investigated whether MYD88 L265P could be identified by peripheral blood (PB) allele-specific PCR. MYD88 L265P was detected in untreated WM (114/118; 96.6%); previously treated WM (63/102; 61.8%); and IgM MGUS (5/12; 41.7%) but in none of 3 hyper-IgM or 40 healthy individuals. Median PB MYD88 L265P ΔCt was 3.77, 7.24, 10.89, 12.33 and 14.07 for untreated WM, previously treated WM, IgM MGUS, hyper-IgM and healthy individuals, respectively (P<0.0001). For the 232 IgM MGUS and WM patients, PB MYD88 L265P ΔCt moderately correlated to bone marrow (BM) disease (r=-0.3553; P<0.0001), serum IgM (r=-0.3262; P<0.0001) and hemoglobin (r=0.3005; P<0.0001) levels. PB MYD88 L265P ΔCt and serum IgM correlated similarly with BM disease burden. For positive patients, PB MYD88 L265P ΔCt was <6.5 in 100/114 (88%) untreated WM, and >6.5 in 4/5 (80%) IgM MGUS patients (P=0.0034). Attainment of a negative PB MYD88 L265P mutation status was associated with lower BM disease (P=0.001), serum IgM (P=0.019) and higher hemoglobin (P=0.004) levels in treated patients. These studies show the feasibility for detecting MYD88 L265P by PB examination, and the potential for PB MYD88 L265P ΔCt use in the diagnosis and management of WM patients.

Over one‐third of African‐American MGUS and multiple myeloma patients are carriers of hyperphosphorylated paratarg‐7, an autosomal dominantly inherited risk factor for MGUS/MM

As hyperphosphorylated paratarg-7 (pP-7) carrier state was shown to be the first molecularly defined autosomal dominantly inherited risk factor for monoclonal gammopathy of unknown significance (MGUS) and multiple myeloma (MM) in a European population, the prevalence of pP-7 carrier state among African-Americans who have a significantly higher incidence of MGUS/MM is of interest. We therefore determined pP-7 carrier state and paraproteins with specificity for P-7 in African-American, European and Japanese patients with MGUS/MM and healthy controls. By isoelectric focusing and ELISA, a paratarg-7-specific paraprotein and the associated pP-7 carrier state was observed in 30/81 (37.0%) African-American, 42/252 (16.7%) European and 7/176 (4.0%) Japanese MGUS/MM patients (p < 0.001). A pP-7 carrier state was found in 11/100 (11.0%) African-American, 8/550 (1.5%) European and 1/278 (0.4%) Japanese healthy controls (p < 0.001), resulting in an odds ratio for MGUS/MM of 4.8 (p < 0.001) among African-American, 13.6 among European (p < 0.001) and 11.5 (p = 0.023) among Japanese carriers of pP-7. We conclude that pP-7 carriers are most prevalent among African-Americans, but a pP-7 carrier state is the strongest molecularly defined single risk factor for MGUS/MM known to date in all three ethnic groups. The high prevalence of pP-7 carriers among African-American patients emphasizes a predominant role of this genetic factor in the pathogenesis of these diseases. The large number of pP7 African-American patients and controls should facilitate the identification of the SNP or mutation underlying the pP-7 carrier state.

BlyS: a potential hallmark of multiple myeloma

Multiple myeloma (MM) is a plasma cell dyscrasia characterized by bone lesions and production of a paraprotein. B-lymphocyte stimulator (BLyS) and its receptor (BAFFR) were highly expressed on peripheral blood and bone marrow B cells in MM patients as compared to those with monoclonal gammopathy of unknown significance (MGUS) and healthy donors. Serum BLyS levels in MM patients were significantly higher than those in MGUS patients and healthy controls. BLyS expression was increased in bone marrow specimens from MM patients as ascertained by immunofluorescence. Furthermore, BLyS, together with IL-2 and IL-6, significantly promoted MM cell proliferation and BLyS receptor expression compared with that in the control group. Treatment with bortezomib, a therapeutic proteasome inhibitor induced apoptosis and repressed the proliferation of RPMI8226 and U266 cells through inhibition of NF-κB p65 and IκBα. These findings suggest that BLyS is involved in the immunopathogenesis of MM and may prove to be a hallmark of MM.

Early Myelodysplastic Changes Present in Substantial Proportion of Monoclonal Gammopathy of Unknown Significance (MGUS) and Smoldering Multiple Myeloma (SMM) Patients

AbstractAbstract 1805 BackgroundResults of three major randomized clinical trials suggest an increase incidence of second primary malignancies (SPM) associated with lenalidomide use in the maintenance setting after alkylator exposure. In parallel, we recently reported the results of a Swedish population-based study, involving 5652 MGUS patients that demonstrated an 8-fold increase risk of developing myelodysplastic syndrome/acute myeloid leukemia (MDS/AML) compared to healthy population with an increased risk demonstrated in patients with IgG/IgA isotypes (not IgM) and M-spikes >1.5 g/dL, suggesting a putative role for disease related factors present in patients prior to therapy initiation. In this prospective clinical study, based on 80 untreated myeloma precursor disease patients (MGUS and SMM), we show early histopathological features and fluorescence in situ hybridization (FISH) abnormalities usually seen in myelodysplasia prior to clinical myeloma disease onset in a substantial proportion of MGUS/SMM patients. MethodsEighty MGUS and SMM patients had baseline bone marrow biopsies, including CD34 immunohistochemical staining, as part of a prospective clinical natural history study (NCT01109407) for myeloma precursor disease. Sixteen (20%; 95% confidence interval: 12%-30%) patients (7 MGUS and 9 SMM) were identified as having dyspoietic morphological features with abnormal high-level CD34+ expression on mature megakaryocytes (CD34+ MEGA), defined as >20% of megakaryocytes in the BM showing membranous/Golgi CD34 immunostaining; these 16 MGUS/SMM patients were defined as cases. As a next step, we carried out a nested case-control analysis. Among remaining 64 MGUS/SMM patients with CD34- expression on mature megakaryocytes (CD34- MEGA), we defined 14 age- and gender-matched subjects (7 MGUS and 7 SMM) as controls. Using prospectively collected clinical and bone marrow data, we applied Mann Whitney and Fisher’s exact tests for differences between CD34+ MEGA (cases) to CD34- MEGA (controls). Fluorescence in situ hybridization (FISH) analysis, using MDS panel [(inv93)(q21q26.2) or t(3,3)(q21;q26.2), -5/5q deletion, -7/7q deletion, +8, 11q23 rearrangements, -13/13q deletion, and -20/20q deletion)] was performed on CD138- fractionated bone marrow aspirate samples from CD34+ MEGA patients (Mayo Cytogenetics Core and Director Patricia T. Greipp, D.O.). ResultsCharacteristics of the CD34+ MEGA patients include median age of 59 yrs (range 45–79), median plasma cell (CD138+) percentage on bone marrow biopsy is 9.8% (range 5–20%), and median M-spike concentrations is 0.95 g/dL (range 0.1–2.1 g/dL) with isotypes 10=IgG, 4=IgA, and 2=IgM. Peripheral blood counts showed no significant cytopenias (median Hgb 13.6 g/dL, WBC 6.3 K/uL, Platelet 239 K/uL). Early dyspoietic features observed in CD34+ MEGA patients compared to CD34- MEGA patients include: hypolobulated megakaryocytes (100% vs. 43%, p=0.0005), micromegakaryocytes (100% vs. 36%, p= 0.0001), bone marrow hypercellularity (48% vs. 38%, p=0.006), and higher myeloblast numbers identified by CD34+ immunostaining (2.8% vs. 1.4%, p=0.005). There were no significant morphological differences in erythroid and myeloid lineages between the two groups. Among 13/16 CD34+ MEGA patients that underwent FISH analysis with MDS panel probes, one patient was identified as having an emerging inv(3) or a t(3;3) clone (1.0% of nuclei found to have fusion of RPN1 and MECOM(EVI11)). ConclusionsIn this prospective clinical natural history study of MGUS and SMM patients, we demonstrate that 16/80 (20%) of untreated myeloma precursor patients demonstrate early dyspoietic morphological features usually seen in MDS. This finding further supports a primary biological link between plasma cell dyscrasias and MDS/AML before clinical disease onset and treatment related exposures occur, and, in the future, it may have implications for choice of therapy for patients who need anti-myeloma treatment. Disclosures:No relevant conflicts of interest to declare.