Bone Marrow Plasma Cell Percentage Research Articles

Decreased Cardiac Ejection Fraction Is Associated with Worse Survival in Patients with Light Chain Amyloidosis Treated with Autologous Stem Cell Transplantation

Decreased Cardiac Ejection Fraction Is Associated with Worse Survival in Patients with Light Chain Amyloidosis Treated with Autologous Stem Cell Transplantation

Treatments and Outcomes of Newly Diagnosed Multiple Myeloma Patients > 75 Years Old: A Retrospective Analysis

Introduction: In general, the use of an immunomodulator (IMiD), proteasome inhibitors (PI) and dexamethasone (dex) for the treatment of MM is associated with better outcomes. The management of elderly patients with multiple myeloma (MM) is challenging due to difficulty in managing their co-morbidities and inability to tolerate treatment side effects. We evaluated therapies and outcomes of elderly patients with newly diagnosed MM. Methods: This is a retrospective study of patients with MM who were >75 years old treated at the Mayo Clinic, Rochester from January 2004 to January 2018. We included patients who were treated on clinical trials as well as off-trials. Patients were classified as receiving treatment with IMiD+PI+dex, alkylator+PI+steroid, IMiD+dex, PI+dex, alkylator+IMid+steroid, and other (alkylator with steroid or steroid only). Treatment response was documented as well as the progression-free (PFS), defined as the time from therapy initiation to disease relapse or death from any cause and overall survival (OS), defined as the time from start of treatment to death from any cause. A multivariate analysis for factors affecting OS was done including the following variables: being on a triplet combination (alkylator+PI+steroid, IMid+PI+dex, or alkylator +IMiD+steroid), revised international staging system (R-ISS)(stage 3 vs. 1-2), bone marrow plasma cell percentage (BMPC%)(>60% vs. ≤60%), and receiving treatment during or after 2010 vs. before 2010. Analysis was done for patients treated off-trials, as well as, including trial patients. Results: We identified 394 patients with MM who were >75 years old and 246 (62%) were male. For non-trial patients (n=350), IMiD+dex (32%) was the most commonly used regimen followed by alkylator with steroid or steroid only (20%), alkylator+PI+steroid (18%), and IMid+PI+dex (13%). The remaining patients were treated with PI+dex (12%) and alkylator +IMiD+steroid (5%). Forty-four patients (11%) were treated in clinical trials with alkylator+IMid+steroid (47%), IMiD+dex (25%), IMiD+PI+dex (14%), and alkylator+PI+steroid (14%). The median follow up was 45.9 months with an interquartile range of 28.2 to 75.6 months. Overall, achieving very good partial response or complete response was more likely in patients who were treated with an IMid+PI+dex (58%) or alkylator+PI+steroid (47%), compared to in other therapies (5-30%)(P<0.0001). The PFS and OS for non-trial patients are displayed in Figure 1 (A,B) and for all, including trial patients in (C,D). Overall, the median OS was significantly longer in patients who were treated with a triplet in non-trial as well as all patients. In a multivariate for OS including non-trial patients, predictors for better OS included receiving a triplet (HR: 0.63, P=0.02) and not having an R-ISS stage 3 (HR: 0.39, P=0.001). This was also found when including trial patients (using a triplet, HR: 0.65, P=0.01 and not having an R-ISS stage 3, HR: 0.35, P=0.0002). Conclusion: In MM patients >75 years old, being able to receive triplet therapy is associated with better survival. This study provides better understanding of the natural history of MM outside of trials in the elderly age group. Disclosures Dispenzieri: Celgene: Research Funding; Alnylam: Research Funding; Pfizer: Research Funding; Intellia: Research Funding; Takeda: Research Funding; Janssen: Research Funding. Dingli:Bristol Myers Squibb: Research Funding; Alexion: Consultancy; Millenium: Consultancy; Rigel: Consultancy; Sanofi-Genzyme: Consultancy; Apellis: Consultancy; Janssen: Consultancy; Karyopharm Therapeutics: Research Funding. Kapoor:GlaxoSmithKline: Research Funding; Amgen: Research Funding; Takeda: Honoraria, Research Funding; Sanofi: Consultancy, Research Funding; Janssen: Research Funding; Cellectar: Consultancy; Celgene: Honoraria. Gertz:Spectrum: Other: personal fee, Research Funding; Janssen: Other: personal fee; Prothena: Other: personal fee; Alnylam: Other: personal fee; Ionis/Akcea: Other: personal fee; Springer Publishing: Patents & Royalties; Proclara: Other; DAVA oncology: Speakers Bureau; Johnson and Johnson: Speakers Bureau; Teva: Speakers Bureau; Sanofi: Other; Research to Practice: Other; Celgene: Other; Abbvie: Other; Aurora Bio: Other; Physicians Education Resource: Other: personal fee; Medscape: Other: personal fee, Speakers Bureau; Amgen: Other: personal fee; Appellis: Other: personal fee; Annexon: Other: personal fee. Kumar:Carsgen: Other, Research Funding; Tenebio: Other, Research Funding; BMS: Consultancy, Research Funding; Karyopharm: Consultancy; MedImmune: Research Funding; Sanofi: Research Funding; Novartis: Research Funding; Kite Pharma: Consultancy, Research Funding; Oncopeptides: Consultancy, Other: Independent Review Committee; IRC member; Genentech/Roche: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Celgene/BMS: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Adaptive Biotechnologies: Consultancy; Merck: Consultancy, Research Funding; Amgen: Consultancy, Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments, Research Funding; Janssen Oncology: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Takeda: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; AbbVie: Other: Research funding for clinical trials to the institution, Consulting/Advisory Board participation with no personal payments; Dr. Reddy's Laboratories: Honoraria; Cellectar: Other; Genecentrix: Consultancy.

The Impact of S-Li-M Criteria in Myeloma in a Real-Life Population: Patient & Disease Characteristics, Treatment and Outcomes from the Australian and New Zealand Myeloma and Related Diseases Registry (MRDR)

The Impact of S-Li-M Criteria in Myeloma in a Real-Life Population: Patient & Disease Characteristics, Treatment and Outcomes from the Australian and New Zealand Myeloma and Related Diseases Registry (MRDR)

Depth of response prior to autologous stem cell transplantation to predict survival in light chain amyloidosis.

8516 Background: The role of induction therapy prior to autologous stem cell transplant (ASCT) in immunoglobulin light chain (AL) amyloidosis remains controversial. Data on the prognostic impact of response to induction in a transplanted cohort are lacking. The aim of this study was to assess the impact of response to induction therapy on survival in patients undergoing ASCT for AL amyloidosis. Methods: We conducted a retrospective study of all newly diagnosed AL amyloidosis patients who received induction prior to ASCT between January 2007 and August 2017 at Mayo Clinic, Rochester, Minnesota. Patients receiving only corticosteroids prior to transplant were excluded as were those with an involved light chain of less than 5 mg/dL (not measurable for response). Results: 134 patients met inclusion criteria. The median age at diagnosis was 60 (range 36-74) and 85 (63%) were men. The most commonly used induction regimen was proteasome inhibitor-based (73.1%, n=98). The overall response rate to induction was 83% (complete response 17%, very good partial response 30% and partial response 36%). With a median follow up of 56.5 months, the median PFS and OS was 48.5 months and not reached, respectively. Response depth to induction therapy was associated with improved PFS and OS and was independent of the bone marrow plasma cell percentage. The median PFS was not reached for patients achieving ≥VGPR prior to ASCT and 33.8 months for patient achieving PR or less (P=0.001). The median OS was longer in patients with deeper responses (not reached for patients achieving ≥VGPR vs. 128 months for patients achieving PR or less (P=0.02). On multivariable analysis, independent predictors of OS were melphalan conditioning dose (RR= 0.38; P=0.018) and depth of response prior to transplant (RR 2.52; P=0.039). Conclusions: Hematologic response prior to transplant predicts post-transplant outcomes in patients with AL amyloidosis. [Table: see text]

Prognostic Role of Beta-2 Microglobulin in Patients with Light Chain Amyloidosis Treated with Autologous Stem Cell Transplantation.

The prognostic impact of increased beta-2 microglobulin (B2M) in patients with light chain (AL) amyloidosis undergoing autologous stem cell transplantation (ASCT) is unknown. The Mayo 2012 stage and increased bone marrow plasma cell (BMPC) percentage are known predictors for survival. Increased B2M is predictive of survival in patients with multiple myeloma. We evaluated the prognostic role of B2M in patients with newly diagnosed AL undergoing ASCT. We retrospectively reviewed patients with a diagnosis of AL amyloidosis who were treated with ASCT between July 1996 and September 2017. Patients with a creatinine level >1.2 mg/dL were excluded, because that affects B2M levels. The receiver operator characteristic curve was used to determine the best cutoff for B2M before ASCT in predicting survival, which was 2.5 µg/mL, which was also the upper limit of normal in our laboratory. Baseline characteristics were compared between patients with B2M >2.5 µg/mL and ≤2.5 µg/mL. Progression-free survival (PFS) was defined as the time from ASCT to relapse or death, whichever occurred first. Overall survival (OS) was calculated from the time of ASCT to death of any cause. Univariate and multivariate analyses were done for OS. Five hundred and ten patients were identified, 222 of whom (44%) had a B2M >2.5 µg/mL. These patients were more likely to be older (median age, 61 versus 57 years;P=.0002), to have Mayo 2012 stage III/IV disease (33% versus 8%; P < .0001), to have more than 2 organs involved (25% versus 14%; P=.001), and to have ≥10% BMPCs (56% versus 40%; P=.0002) compared with patients with B2M ≤2.5 µg/mL. The median PFS and OS were shorter in patients with B2M >2.5 µg/mL (median PFS, 64 months versus 80 months [P=.03]; median OS, 104.9 months versus 175.5 months [P < .0001]). On univariate analysis, predictors for OS included age >60 years (hazard ratio [HR], 1.61; P=.001), Mayo 2012 stage III/IV (HR, 3.36; P < .0001), more than 2 organs involved (HR, 1.36; P=.07), ≥10% BMPCs (HR, 1.5; P=.005), melphalan conditioning with 200 mg/m2 (HR, .29; P < .0001), B2M >2.5 µg/mL (HR, 1.82; P < .0001), and transplantation during or after 2010 (HR, .4; P=.0006). On multivariate analysis, only Mayo 2012 stage III/IV (HR, 1.89; P=.005), melphalan conditioning with 200 mg/m2 (HR, .39; P < .0001), B2M >2.5 µg/mL (HR, 1.84; P=.003), and transplantation performed during or after 2010 (HR, .58; P=.03) remained independent predictors of OS. Our findings identify B2M >2.5 µg/dL before ASCT as an independent predictor for OS in patients with AL amyloidosis and normal kidney function and should be routinely measured.

Glucose Regulated Protein (GRP78) as a Biomarker of Response to Bortezomib‐based Regimen in Multiple Myeloma

IntroductionGRP78 overexpression has been associated with bortezomib resistance in multiple myeloma (MM) cells. However, serum GRP78 as a maker of bortezomib based treatment response remains unexplored. The objective of the study was to evaluate serum GRP78 levels in MM patients who underwent bortezomib based induction regimen.MethodsAfter ethical approval, this cross‐sectional study was done in adult MM patients who had completed at least 4 cycles of bortezomib based induction therapy. They were classified into responders (complete response (CR), very good partial response (VGPR), partial response (PR)) and non‐responders (stable disease (SD) and progressive disease (PD)). Thirty healthy volunteers and twenty newly diagnosed multiple myeloma patients were also recruited to identify the disease associated change in GRP78 levels. Serum GRP78 was estimated by ELISA. Surface and intracellular expression of GRP78 in bone marrow plasma cells was evaluated in a subset of MM patients by flowcytometry.ResultsThirty MM patients who completed at least 4 cycles of bortezomib based induction therapy [median(range): 52 (38–68) years; Male:20] were enrolled. Out of 30 patients, 20 were responders and 10 were non‐responders. They were comparable at baseline in all clinical and laboratory parameters except serum M protein which was significantly higher in non‐responders (p=0.04). Serum GRP78 levels were not significantly different between responders [median (IQR): 5.2 (3.1,8.0) μg/ml] and non‐responders [median (IQR): 4.3 (0.1,7.1) μg/ml] (p=0.356). Although non‐significant (p=0.342), median serum GRP78 was higher in newly diagnosed patients when compared to healthy volunteers. Bone marrow plasma cell percentage ranged between 0.2 to 57.8% in the analyzed samples. Intracellular GRP78 expression was found to be higher (1.6 to 5 times) when compared to surface expression in plasma cells as well as in malignant subset of plasma cells.ConclusionSerum GRP78 did not differ between responders from non‐responders in MM patients who underwent bortezomib based induction regimen.Support or Funding InformationIntramural Research Grant

Short-Term Risk of Progression of Patients with Asymptomatic Monoclonal Gammopathies to Active Multiple Myeloma: The Critical Impact of the Tumoral Mass

The identification of risk factors for progression is critical in the clinical management and appropriate follow up of patients with pre-malignant Asymptomatic Monoclonal Gammopathies (AMG) including Monoclonal Gammopathy of Undetermined Significance (MGUS) and Smoldering Multiple Myeloma (SMM). The development of prognostic score and consequently the early identification of patients with possible short-term progression to Multiple Myeloma (MM) could lead to anticipate the treatment. In this study, we retrospectively evaluated possible risk factors of short-term progression to active MM in a large cohort of MGUS and SMM patients admitted to a single haematological center (Hematology and BMT Unit, University Hospital of Parma) between 2010 and 2018. We analysed a total cohort of 235 patients diagnosed with AMG (81 MGUS and 154 SMM) according to the IMWG recently updated diagnostic criteria. All patients analysed underwent to Bone Marrow (BM) examination; moreover, imaging evaluation was performed in 22 MGUS and 123 SMM patients, in order to exclude the presence of bone disease. In a subgroup of AMG patients (n=50), bone mineral density (BMD) evaluation by Dual-energy X-ray Absorptiometry (DXA) was also available. Median age of the AMG patients analysed was 68 years (range 35-93 years). Median percentage of BM plasma cells (BMPCs) was 12% (range 2-55%) in the entire population, 7% (range 2-9) in MGUS and 15% (range 10-55) in SMM patients. Median serum M-protein was 1.7 g/dL (range: 0.17-4.5), 1.5 g/dL (range 0.17-4.5) in MGUS and 1.8 g/dL (range 0.4-2.7) in SMM patients. An abnormal free light chain (FLC) ratio was found in 70% of AMG patients, among the ones that performed the analysis; regarding SMM patients, FLC ratio value was available in 97 patients: in 72 (76%) the ratio was unbalanced, 37 (39%) had a FLC ratio ≤ 0.125 or ≥ 8 and in 14 (15%) it was &gt; 20; among MGUS patients, value was collected in 41 patients and in 21 (51%) it was &lt;0.26 or &gt;1.65. The presence of immunoparesis in one or two uninvolved immunoglobulins occurred in 59% of the entire population. The median follow up time was 18 months (range 0 - 111 months) for whole population. Overall 44 patients of the entire cohort progressed to MM (41 SMM and 3 MGUS) with a median TTP of 14.5 months. By univariate analysis we found that percentage of BMPCs, entity of M-protein and presence of immunoparesis were significantly correlated with progression to active MM (p&lt;0.001 for each variable). On the other hand, abnormal FLC ratio did not reach a statistical significance, as well as value of the involved FLC (p=0.059). Nevertheless, the presence of a FLC ratio &lt; 0.125 or &gt; 8 (as used in Mayo scoring system for SMM) showed a relationship at the limit of statistical significance in this subgroup of patients (p=0.052). Any significant correlation was not observed with age, sex, Ig isotype, light chain's type and the BMD values (p=NS). Afterwards, we applied Kaplan Meier method on risk factors resulted significant in univariate analysis demonstrating that they also significantly influenced the time to progression to MM. Finally, through a binomial logistic regression, we developed a new prognostic score for whole population. By combining the values of M-protein (&lt; 2, score=0 or ≥ 2 g/dL, score=1) and the percentage of BMPC (&lt;10%, score=0, 10-20%, score=1 and &gt;20%, score=2), we obtained six groups at different probability of progression to active MM (Table 1). Given that result, we stratified patients in 3 groups: low-risk (score=0), intermediate-risk (score=1) and high-risk (score≥2); log-rank test confirmed that high-risk patients had a significantly shorter time to progression to symptomatic MM as compared to intermediate and low-risk patients (p&lt;0.001). In conclusion, our results show that in patients with AMG the clinical factors, which mostly impact on the short-term risk of progression to active MM, are the entity of the PCs infiltrate and the MC related to the tumoral mass. The development of a clinical score based on BMPCs and M-protein will permit to overcome the traditional distinction between MGUS and SMM in the evaluation of the progression of AMG patients to active MM. Disclosures Giuliani: Janssen: Research Funding.

B-Cell Maturation Antigen (BCMA) in Systemic Light-Chain Amyloidosis (AL): Association with Disease Activity and Its Modulation with Gamma-Secretase Inhibition

Introduction: Systemic light-chain (AL) amyloidosis results from clonal plasma cells that secrete toxic fibril-forming free light chains. Therapies directed at the plasma cell clone form the backbone of its management. Identification of cell-surface receptors on the clonal cells can provide targets for therapy. BCMA is one such cell-surface glycoprotein; it is principally expressed on plasma cells and supports their long-term survival (J Exp Med. 2004;199:91-98). Anti-BCMA immunotherapies are currently being studied in multiple myeloma (N Engl J Med. 2019;380:1726-1737). Membrane-bound BCMA (mBCMA) is also shed as a soluble form, sBCMA, due to γ-secretase activity that can be inhibited by a small molecule (GSI, LY-411575) (Nat Commun. 2015;6:7333; J Immunol. 2017;198(8):3081-3088). We report on mBCMA on the clonal plasma cells of AL patients and its modulation by GSI in vitro, and on sBCMA in the blood of AL patients and of mice xenografted with an AL cell line, demonstrating its correlations in vivo with free light chain (FLC) levels and plasma cell tumor burden. Methods: We analyzed mBCMA and sBCMA levels in marrow aspirate and peripheral blood samples from AL patients under an IRB approved protocol. We isolated mononuclear cells (MNC) from patient marrow aspirates with anti-CD138 microbeads (Miltenyi Biotec, Auburn, CA), and used the CD138-selected cells in culture with LY-411575 (Sigma Aldrich, St Louis, MO). We analyzed mBCMA expression by flow cytometry using APC conjugated anti-CD269 (BCMA) antibody (Biolegend, San Diego, CA, USA) and CD138 expression by PE-conjugated anti-CD138 antibody (Biolegend, San Diego, CA, USA), along with appropriate isotype controls. We injected 107 ALMC-1 reporter cells in the flanks of NOD scid gamma (NSG) mice to create a xenograft model of AL clonal plasma cell disease (Jackson Laboratories, Bar Harbor, ME). sBCMA in patients and mice and FLC in mice were measured by ELISA (R&amp;D Systems, Minneapolis, MN; Bethyl lab Montgomery, TX respectively). Pearson and Spearman correlation analysis was used to examine associations of sBCMA and clinical disease parameters. Paired t-test was applied to compare BCMA expression before and after treatment with GSI. Results: Marrow and blood were obtained from 20 AL patients, 8 newly diagnosed, 4 with progression of disease, and 8 after treatment with &gt;VGPR. Their median age was 65 years (range, 48-77) and 50% were female. Median plasma cells in the marrow aspirates and involved FLC levels were 5% (1-20%) and 33 mg/L (6.6-2220mg/L) respectively. Median mBCMA expression on CD138+ marrow MNC and sBCMA levels in plasma were 39% (4-83) and 28.5 ng/ml (6.6-100.3) respectively (Figure 1A-B). sBCMA levels correlated with bone marrow plasma cell percentage and iFLC (both p&lt;0.001, Figure 1C-D). In culture with LY-411575, the percentages of CD138 cells positive for mBCMA increased from 85% to 100% with ALMC-1 cells and from 36% to 68% (p &lt; 0.01) with patient CD138-selected cells while the sBCMA levels in culture supernatant decreased by over 50%. In NSG mice with ALMC-1 reporter cell xenografts, medians of luciferin-based bioluminescence FLUX (photons/s), λ FLC and sBCMA were 3.9x1010 (2.02x109-1.2x1011), 949.1 mg/L (868.8-23629.2), and 3.8 ng/ml (0.9-23.6) respectively. sBCMA levels correlated with FLC (Pearson r= 0.99, p&lt;0.0001) and with FLUX (Pearson r=0.61, p=0.07). Conclusions: BCMA is expressed on AL plasma cells and sBCMA is detected in the blood of all AL patients. In this light chain disease, sBCMA may be useful as a marker of disease activity even in patients with low FLC. Furthermore, expression of mBCMA can be manipulated by treatment with a GSI, an approach which may be useful therapeutically in AL. These results provide the basis for applying anti-BCMA immunotherapies in clinical trials in relapsed refractory AL patients. Disclosures Comenzo: Sanofi-Aventis: Membership on an entity's Board of Directors or advisory committees; Unum: Membership on an entity's Board of Directors or advisory committees, Research Funding; Takeda: Research Funding; Caelum: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm: Research Funding; Prothena Biosciences: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Myself: Patents &amp; Royalties: Patent 9593332, Pending 20170008966.

Treatment with Novel Agents in Patients with Multiple Myeloma in México: Data of Characteristics, Treatment Patterns and Outcomes from a Health Care System

Introduction: In the last decade, multiple myeloma (MM) therapy has changed due to management strategies including proteasome inhibitors and immunomodulatory drugs. However, in México these drugs are not affordable for every health care system so there is little data regarding treatment with these agents and their outcomes. Methods: We retrospectively reviewed the clinical records of patients diagnosed with MM from January 2004 to June 2018, at different hospitals from the Petróleos Mexicanos healthcare services in México. Diagnosis and treatment response were defined according to the International Myeloma Working Group (IMWG) criteria. Baseline and follow-up characteristics and dates of progression, recurrence, death or last follow up were recollected. Overall survival (OS) was calculated from the date of diagnosis to the date of death from any cause or last follow-up. Event free survival (EFS) was defined from date of diagnosis to the time of progression, relapse or death from any cause or loss of follow-up. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Risk factors related to EFS and OS were identified through univariate and multivariate analysis by means of Cox proportional Hazard regression model. Results: A total of 145 patients with MM were included. Median age at diagnosis was 66 years (range 33-94); 38% were female. The most frequent serum monoclonal protein type was IgG. At the time of presentation, 9% of patients had hypercalcemia; 30% renal insufficiency; 83% had anemia &lt; 10 g/dL; 81% osteolytic lesions and 30% had bone marrow plasma cell percentage ≥60%. ISS stages I, II and III were present in 20%, 27% and 53% of cases. 60% of patients received bortezomib-based induction treatment. Only 6% were treated using the combination of bortezomib and lenalidomide plus steroid, and 2% with lenalidomide plus dexamethasone as first line induction regimen. The rest of the cohort received treatment using melphalan, thalidomide or anthracycline-based chemotherapy. The median follow-up was 47 months (range 2-182). Median OS for the entire cohort was 56 months (95% confidence interval [CI] 42.3-69.7). Six patients (4%) died within six months of diagnosis from renal failure and infections attributed to the disease. 106 patients had evaluable response according to IMWG criteria. Overall response rate was 76% (Complete response 26%; very good partial response (VGPR) 38%; partial response 29%). Only 21 (14%) patients underwent autologous stem-cell transplantation (ASCT). All cases received novel agents as first line regimen and achieved VGPR or better before the procedure. 53 (50%) relapsed during follow up. 38% received second line treatment with lenalidomide-based regimens and 11% were treated with carfilzomib, immunomodulatory drug and steroid combination. Median OS was 56 months (95% Confidence Interval [CI], 42.3- 69.7). Patients older than 65 years had worse OS (31 months; 95% CI, 19.7-42.3) compared to younger patients (53 months; 95% CI, 25.3-60.7; P= 0.001) as well as those with advanced Durie- Salmon stage or ISS score. Treatment with novel agents had no impact in OS in comparison to other regimens (median 75 months vs 44 months, P = 0.21). On the other hand, in those who received ASCT as consolidation, OS was 130 months compared to 61 months in the group treated with chemotherapy alone. On univariate and multivariate analysis, we identified age &gt; 65 years (hazard ratio [HR] 2.6; 95% IC 1.45- 4.7; P = 0.01) and ASCT (HR 0.3; 95% IC 0.12- 0.77; P = 0.012) as statistically significant factors for survival. Median EFS was 30 months (95% CI, 20.7- 39.9). We observed a trend towards a better EFS in patients treated using bortezomib and/or lenalidomide-base regimens (36 months; 95% CI, 21.5- 50.5) compared to those who received other treatment strategies (26 months; 95% CI, 13.4-38.6; P = 0.093). Univariate analysis identified age &gt; 65 years (HR 2.1; 95% IC 1.36- 3.42; P = 0.01) as a significant factor for worst EFS; and VGPR or better (HR 0.54; 95% IC 0.45- 0.65; P = 0.001) as well as ASCT (HR 0.34; 95% IC 0.175- 0.67; P = 0.002) as factors associated to better outcomes. Only age and ASCT remained as independent prognostic factors on multivariate analysis. Conclusion: Outcomes on this study are similar to the reported by other series in México and Latin America. These findings reinforce the need to expand and improve access to better treatments and health coverage in México. Figure Disclosures No relevant conflicts of interest to declare.

Using Current Clinical Markers to Define High Risk Smoldering Multiple Myeloma: Agree to Disagree

Using Current Clinical Markers to Define High Risk Smoldering Multiple Myeloma: Agree to Disagree

Update on Risk Stratification Model of Smoldering Multiple Myeloma: A Systematic Review

Background: Smoldering multiple myeloma (SMM) was stratified into risk classes based on several models including Mayo clinic and Spanish myeloma working group models. After the revision of diagnostic criteria for multiple myeloma (MM) in 2014, the ultra-high risk SMM patients (&gt;80% clonal plasma cells at two years) were re-classified as active MM patients. Thus, predictors of progression in patients currently diagnosed as SMM are unknown and reassessment of existing models is required. We aim to identify the risk factors associated with progression in SMM patients classified according to updated guidelines. Methods We performed a literature search following PRISMA guidelines and used following bibliographic databases: MEDLINE (Ovid and PubMed), EMBASE, The Cochrane Library and Cochrane Central Register of Controlled Trials (CENTRAL), as well as annual meetings abstracts from inception till 1st,August 2019. We used MeSH and Emtree terms as well as performed open search for "smoldering multiple myeloma", "smoldering myeloma", and "asymptomatic multiple myeloma". Two independent reviewers screened the literature. We used snowballing technique to screen abstracts and reference within articles to include titles. Cochrane collaboration tool was used to asses risk of bias among included studies Results Our search retrieved 419 titles. After going through the titles and abstracts 38 articles were selected for full text review. Final review led to inclusion of 11 articles. Levels of serum M proteins, percentage of bone marrow plasma cells (BMPCs), serum free light chain ratio (FLCr) and PET/CT scan findings of whole body were most consistently and reliably indicated the progression of SMM to MM (Table 1). New studies are suggesting that B-cell maturation levels (BCMA), evolving M-proteins (eMP) and evolving hemoglobin levels (eHb) are also an accurate measure of SMM progression and should be incorporated in the risk stratification models. A study by Gonsalves WI et al. also suggested that levels of circulating clonal plasma cells with a cutoff of 150 was an important prognostic marker in their study. Immunoparesis status and role of Bence Jones proteins in reliably predicting the progression of SMM was debatable because they were significant in univariate analysis but were not significant in multivariate analysis (Table 1). Conclusion Serum M protein levels (2 g/dL), percentage of BMPCs (20%), serum FLCr (20) and PET/CT scan were reliable in predicting the prognosis of smoldering MM. New techniques like B-cell maturation levels(74.4 ng/mL), evolving M-proteins and evolving hemoglobin levels can play a significant role in proposing future risk predictive models of SMM. Role of immunoparesis and Bence Jones proteins is debatable. Table 1 Disclosures Anwer: Seattle Genetics: Membership on an entity's Board of Directors or advisory committees; In-Cyte: Speakers Bureau.

Prognostic Implications of Metabolic Total Volume and Total Lesion Glycolysis Assessed By PET/CT Combined with High Levels of Bone Marrow Plasma Cells Percentages As a Potential Risk Model in Patients with Newly Diagnosed Multiple Myeloma

Introduction: Multiple myeloma (MM) is a heterogeneous malignant plasma cell (PC) disorder and the survival ranges from several months to &gt; 10-years. Several risk stratification systems such as the Revised International Staging System (R-ISS) have been developed. PET/CT allows the direct assessment of metabolic tumor burden in various malignancies. Therefore, metabolic tumor volume (MTV) and total lesion glycolysis (TLG), which are volumetric parameters applicable to PET/CT, are emerging tools for MM prognostication. This study was aimed to determine the value of MTV and TLG using PET/CT in the prognostication and in combination with various hematologic parameters such as bone marrow PC (BMPC) percentages and circulating tumorous PCs (CPCs) to identify the patients with high-risk features. Methods: A total of 196 consecutive patients with newly diagnosed MM (NDMM) who underwent baseline whole-body PET/CT between January 2009 and June 2019 at Kameda Medical Center, Kamogawa-shi, Japan, were retrospectively analyzed. PET/CT was performed using dedicated PET/CT scanners (Discovery ST Elite Performance; GE Healthcare, Milwaukee, USA). The standard uptake value (SUV) was normalized according to the injected dose and lean body mass. The baseline SUVmax of all lesions was recorded, and the highest value was considered as the SUVmax of the patient. MTV was defined as the myeloma lesions volume visualized on PET/CT scans with SUV greater than or equal to the fixed absolute threshold of SUV = 2.5. TLG was calculated as the sum of the product of average SUV (SUVmean) and MTV of all lesions. Computer‐aided analysis of PET-CT images for MTV and TLG calculations was performed using an open-source software application of Metavol (Hokkaido University, Sapporo, Japan). The CPCs were measured using an 8-color flowcytometry and reported as the percentage per total mononuclear cells using the monoclonal antibodies of CD19, 38, 45, 56, 117, 200, κ, λ, and CD138. The BMPC was calculated by counting the percentages of CD138-stained PCs among the all nucleated cells on bone marrow biopsy samples. Eleven patients (13.8%) were excluded because the MTV data could not be retrieved. Ultimately, 185 patients were included in our analysis. Written informed consent was obtained from all patients. Results: Among the 185 patients, 28 patients (15.1%) were negative for avid lesion on PET/CT. Whole-body MTV and TLG ranged from 0 to 2440.7 mL, with a median of 34.2 mL and from 0 to 12582.4 g, with a median of 97.0 g, respectively. The best cut-off values of MTV and TLG that discriminate the survival using a receiver-operating-characteristic curve analysis were 56.4 mL and 166.4 g, respectively. The overall survival (OS) and progression-free survival (PFS) of patients with a lower cut-off value of MTV (≤56.4 mL) had better survival with not reached (NR) and 37.3 months as compared to those with a higher cut-off value (&gt;56.4 mL) that reached 52.9 and 23.8 months, respectively (p=0.003 and 0.019). Similarly, the OS and PFS of patients with a lower cut-off value of TLG (≤166.4 g) showed better survivals with NR and 37.3 months as compared to those with a higher cut-off value (&gt;166.4 g) that reached 54.3 and 28.8 months, respectively (p=0.0047 and 0.012). Next, we explored the prognostic impact of the clinical variables including MTV or TLG, CPCs, and BMPC. High levels of CPCs and BMPCs levels were defined as ≥0.018% of the total mononuclear cells and BMPCs of ≥57%, respectively. Univariate analysis showed that age≥70, serum creatinine≥2.0 mg/dL, R-ISS stage 3, higher cut-off value of MTV, and higher cut-off value of TLG were the associated with shorter OS. To measure the tumor volume with accuracy, we combined BMPC or CPCs and MTV or TLG. On multivariate analysis, age≥70 and the combination of higher cut-off value of MTV or TLG and high level of BMPC percentage were significantly associated with shorter OS [Hazard Ratio (HR) 2.12, p=0.038, HR 2.66, p=0.027 and HR 2.57, p=0.029, respectively] and PFS (Not assessed, HR 2.52, p=0.018 and HR 2.7, p= 0.011, respectively) (Figure 1). Conclusion: Our findings demonstrated that MTV and TLG calculated from pretreatment PET/CT were useful for risk stratification in patients with NDMM when combined with BMPC. The prognostic performance of the combined high-burden of TLG or MTV and high levels of BMPC were independent of the established risk factors. Disclosures Matsue: Novartis Pharma K.K: Honoraria; Janssen Pharmaceutical K.K.: Honoraria; Celgene: Honoraria; Takeda Pharmaceutical Company Limited: Honoraria; Ono Pharmaceutical: Honoraria.

Cytogenetic Features and Clinical Outcomes of Patients With Non-secretory Multiple Myeloma in the Era of Novel Agent Induction Therapy

BackgroundNon-secretory multiple myeloma (NSMM) is a rare subtype of multiple myeloma (MM) characterized by the absence of monoclonal protein in the serum and/or urine. We look at the clinical and cytogenetic features of NSMM in this study. Patients and MethodsThis study evaluates a cohort of 30 patients with newly diagnosed NSMM seen at the Mayo Clinic, Rochester, MN, between 2008 and 2018 and treated with novel agent induction therapies. Survival outcomes were estimated using the Kaplan-Meier method and compared using the log-rank test. ResultsThese patients with NSMM appear to have a large disease burden at diagnosis with a median bone marrow plasma cell percentage of 70% and more than one-half of all patients having Multiple Myeloma International Staging System Stage III disease. There was a higher preponderance for t(11;14) primary cytogenetic abnormality in this NSMM cohort, accounting for more than 50% of the cohort. Finally, the overall survival of this cohort appears to be slightly worse than a matched-control group of newly diagnosed patients with MM with secretory disease. ConclusionsFuture multi-institution studies confirming these above findings on this rare entity are warranted.

IgH-V(D)J NGS Study on Non-CR patients with Negative MRD by Next Generation Flow

According to the treatment response criteria by International Myeloma Working Group (IMWG), treatment response is categorized on the basis of bone marrow (BM) plasma cell (PC) percentage, and the amount of remaining light chain and M-proteins. Recently, the survival and complete response (CR) rates of multiple myeloma (MM) patients have rapidly increased with the development of novel agents. However, despite the high CR rate, the recurrence rate remains high. Therefore, there is a great need for a more sensitive and accurate method to detect minimal residual disease (MRD).

Contribution of Bence-Jones proteinuria to the monoclonal gammopathy diagnosis based on serum free light chains

Multiple Myeloma (MM) is the second most common hematological malignancy after non-Hodgkin lymphoma and is manifested by uncontrolled proliferation and accumulation of abnormal plasma cells in the bone marrow (BM). The incidence along with deaths associated with MM is on rise due to lack of an effective diagnosis at an early stage. The identification of MM decades ago marks the adoption of certain conventional markers such as plasma cell percentage in BM, serum protein electrophoresis for M-band and urinary Bence-Jones protein. This was then followed by utilization of β2 microglobulin and serum albumin for determining the staging of MM. The need for a better diagnostic or prognostic marker prompts researchers and hence, certain novel markers have been tested which includes extracellular matrix proteins, angiogenic factors, telomeres and telomerase along with the immune markers. Nowadays, proteomic and genomic studies are being performed to identify novel diagnostic and/or prognostic markers for MM. Followed by this, comes the emerging concept of liquid biopsy which allows easy and non-invasive detection of the disease. The liquid biopsy comprises of circulatory tumor cells along with the nucleic acids (microRNAs and cell-free DNA) released from the tumor cells in peripheral circulation which could be a true representation of BM. This review, hence, summarizes the emerging biomarkers involved in the diagnosis and prognosis of MM.

Biochemical Characterization of Multiple Myeloma Patients across ISS Stages – A Data Base Workup from a Tertiary Care Hospital in India

Background: Multiple myeloma (MM) is slowly becoming a huge medical burden, challenging the health-care systems of Asian countries. Because of the unavailability of widespread access to various modalities of investigations, and paucity of well compiled data on common presenting features and various laboratory parameters in various stages of MM in India, the diagnosis is usually delayed till complications begin to occur. This study is an attempt to fill this gap and to establish database for future reference. Methods: The study was conducted in a tertiary health care centre over a span of 3 years and 94 patients diagnosed as MM with complete workup including beta2 microglobulin (β2M), bone marrow plasma cell percentage, serum protein electrophoresis, serum and urine Immunofixation and serum Free Light Chains (FLC) were included. The various laboratory parameters were statistically analyzed across ISS stages I, II and III. Results: We found a male to female ratio of 1.47:1. The mean age of patients was 55.5±11.78 yrs. Backache was the most frequent presentation (30%) of the patients followed by generalized weakness (22%). The percentage of plasma cells, hemoglobin, urea, creatinine, uric acid, calcium and β2M showed significant difference across the stages. 38.3% of the patients were in stage III, 29.8% in stage II and 31.9% in stage I. IgGκ type constituted 70%, other fraction being IgGλ (10%), IgMκ (10%), IgAκ (5%) and IgAλ (5%). M band was not seen in 11% of patients.Conclusion(s): The presentation of MM is nonspecific and patient can come with varied presentations at onset. We have biochemically characterized the three stages of MM and this will form a basis for further larger studies on these lines and to develop stage-based algorithms for early and better diagnosis and prognosis of MM.

Classification OMS 2017 des tumeurs plasmocytaires

Plasma cell neoplasms represent an heterogeneous group of pathologies including plasma cell myeloma, smoldering plasma cell myeloma, non-IgM of undetermined significance (MGUS), plasmocytoma, disorders defined by tissue immunoglobulin deposition like primary amyloidosis, and clonal plasma cell proliferations with an associated paraneoplastic syndrome. Plasma cell neoplasms share a common origin resulting from expansion of heavy chain class-switched terminally differentiated B-cells (plasma cells) that typically secrete a single monoclonal immunoglobulin called M protein. Diagnostic criteria recommended by International Myeloma Working Group (IMWG) and adopted by this fourth revision of WHO classification (2017) are precise and relie on extensive clinical, biological and imaging data. Bone marrow plasma cell percentage, serum and urinary M protein concentration, plasma cells related end-organ damage (CRAB signs : hypercalcemia, renal insufficiency, anemia, and bone lesions) and imaging features of bone lesions are all key factors leading to the distinction of different plasma cell neoplasms.

Impact of bone marrow plasma cells percentage on survival at diagnosis and pre-transplant period in newly diagnosed multiple myeloma: Experience of a single center from Turkey

Background and aimThe current definition of complete remission (CR) in multiple myeloma (MM) includes negative serum and urine immunofixation (IFE) tests and <5% bone marrow plasma cells (BMPCs). The aim of this study was to examine the impact of BMPC percentage on survival, at diagnosis and pre-transplant period, in newly diagnosed multiple myeloma. Materials and methodsOne hundred and fourty eight patients with newly diagnosed MM who had received autologous stem cell transplantation (ASCT) in our HSCT (hematopoietic stem cell transplant) center at Hacettepe University Hospital between the years of 2008 and 2018 were evaluated retrospectively. ResultsThe median follow-up period was 27.4 months (range, 4.5–122) for the entire group. The 3-year OS was 87% in the pre-transplant BMPCs <5% group and 92% in the pre-transplant BMPCs ≥ 5% group, there was no statistically significant difference. The 5-year OS for the pre-transplant BMPCs <5% group and the pre-transplant BMPCs ≥ 5% group were 73% and 70%, respectively (p = 0.50). The 3-year PFS in the pre-transplant BMPCs <5% group and the pre-transplant BMPCs ≥ 5% group were 77% and 57%. The 5-year PFS in the pre-transplant BMPCs <5% group and the pre-transplant BMPCs ≥ 5% group were 43% and 13%, respectively. There was a statistically significant difference between the two groups with respect to PFS (p = 0.04). ConclusionIn conclusion, this study highlights the importance of reaching <5% BMPCs at pre-transplant period. OS and PFS were better in patients who had pre-transplant BMPCs <5% than pre-transplant BMPCs ≥ 5%.

High and Low Tumor Infiltration Affect the Differences Among the Detection of Plasma Cells Evaluated in Bone Marrow By Flow Cytometry, Aspirate and Biopsy(Grupo Interdisciplinario de Mieloma Multiple, Hospital Universitario Fundacion Santa Fe, Colombia)

BackgroundIn plasma cell neoplasms, the percentage of plasma cells in bone marrow (PPCBM) is important for diagnosis and assessment of the treatment. This quantification is performed using bone marrow multiparameter flow cytometry (FC), aspirate smears (BMA) and biopsy. Differences among the percentage of infiltration detected by these techniques have been reported, which can be related to a heterogeneous pattern of infiltration of multiple myeloma (MM) or sample quality. However, a simultaneous evaluation of these three techniques has not been reported nor their ability to detect bone marrow involvement with high or low infiltration, associated with different stages of this disease.PurposeThe aim of this study was to compare the results of PPCBM obtained by FC, BMA, and biopsy with CD138 immunohistochemistry (BMB) in different stages of the disease with high and low infiltration, and the ability of these techniques to correctly classify the disease.MethodsPathological studies of patients referred to Hospital Fundación Santa Fe, Colombia were reviewed between January 2015 and June 2018. The selection of patients was based on both, a diagnosis of plasma cell neoplasms, classified according to the International Myeloma Working Group criteria and the simultaneous use of FC by FACSCanto II flow cytometer (Infinicyt 2.0 software program), wright-stained aspirate smears and biopsy with CD138 immunohistochemistry in the detection.Descriptive analysis was performed and PPCBM was expressed as the mean± standard error of the mean (SEM). The Kruskal-Wallis test was used to compare the mean of PPCBM among the three methods. Lineal regression and Spearman´s coefficient were used to correlate the variables. Statistical association was considered significant for p values <0.05.ResultsA total of 130 patients with plasma cells neoplasms were included in this study, 57 with newly diagnosed MM (N), 58 following therapy MM (F) and 15 MGUS patients. In the N patients, the mean of infiltration was 12.3% ±1.8, 30.3% ±3.4 and 52.2% ±3.74 detected by FC, BMA and BMB, respectively. The PPCBM detected by this three analysis were significantly different (p<0.001). In F patients, the mean of infiltration was 0.37% ±0.05, 1.88 % ±0.16 and 2.61% ±0.21 while in MGUS-patients was 0.49% ±0.09, 2.067 % ±0.37 and 2.4% ±0.28 detected by FC, BMA and BMB, respectively. For F and MGUS patients, significant statistic differences between BMB and BMA versus FC (p<0.01) were observed, but not between BMB and BMA (Figure 1).In the comparative analysis of the three methods in all patients, the highest infiltration was always detected by BMB, followed by BMA and finally by FC (p<0.01) (Figure 2). Linear regression established that for each 1% of infiltration detected by FC or BMA, the BMB identified 2.11% and 1.4% of infiltration, respectively (Figure 2). However, each univariate model only explained 55% and 67% of the observed results. Notably, there was a high correlation among these three techniques (Spearman´s coefficient > 0.8).Finally, given that there are important PPCBM such as ≥10 that allows establishing the diagnosis of MM or ≥60%, considered an MM definitive event, we found that 21% and 52% of cases assessed by BMA and FC had PPCBM <10%, but all of them were reclassified as MM with BMB. None case had PCBM <10% using BMB. Finally, among all cases diagnosed as MM, there were identified 26 by FC and 35 cases by BMA with a PCBM percentage between 10 and 59%, of which 84% and 54% respectively had ≥60% of involvement detected by BMBConclusionIn the comparison of the PCBM was observed a high linear correlation between MFC, BMA, and BMB, although we found a differential behavior of these methods, depending on the level of tumor infiltration.High percentages of infiltration, such as newly diagnosed MM patients, the BMB detected significantly more PPCBM than the others two methods (1.7 to 4-fold compared to BMA and FC). This supports the systematic incorporation of BMB into the analysis of patients with suspected MM for allowing a proper classification of disease.With low percentages of infiltration, such as MGUS and following therapy patients, the difference of PPCBM between BMA and BMB was not significant. Although, FC detectedthe lowest percentage of infiltration, it known its high specificity to discriminate tumor and normal plasma cells, being in one of the most important analysis to monitor minimal residual. DisclosuresNo relevant conflicts of interest to declare.

Clinical Characteristics and Outcome of Patients with Wild-Type Transthyretin and AL Cardiac Amyloidosis Confirmed By Mass Spectrometry

INTRODUCTIONCardiac involvement is common in both wild-type transthyretin (wATTR) and AL amyloidosis and these entities can have overlapping clinical features (Banypersad et al, JAHA 2012). Accurate diagnosis is vital given differences in spectrum of disease, management, and prognosis. We examined the presenting clinical features and survival outcome of patients diagnosed with cardiac wATTR and AL amyloidosis confirmed by mass spectrometry.MATERIALS & METHODS: Patients diagnosed between January 2014 and September 2017 with biopsy proven wATTR or AL amyloidosis and cardiac involvement by consensus criteria (Gertz et al, Amyloid 2010) were included. Mass spectrometry testing was performed at the Mayo Clinic Laboratories to confirm amyloid subtype in all cases. Patient records were retrospectively reviewed to identify clinical characteristics as well as details regarding treatment and survival. RESULTSForty-three patients were identified (wATTR n=27, AL n=16) with site of biopsy: 41 cardiac (95%); 1 gastric (2%); 1 skin (2%). Two (13%) patients with AL amyloid had coexisting multiple myeloma. Thirty-five (81%) patients were male, with a strong male predominance in wATTR patients (100% vs 50% for AL patients, p=<0.01). Median age at diagnosis was 73 years (range 45-86), with a trend towards older age in wATTR patients (median 75 vs 62 years for AL patients, p=0.09). No difference was seen in presenting NYHA class or levels of troponin and ntProBNP between amyloid subtypes. BNP trended towards higher values in AL patients (median 514 vs 249 ng/L for wATTR, p=0.09). wATTR amyloid patients had lower median presenting left ventricular ejection fraction (43 vs 53%, p=0.05). Two (7%) patients with wATTR amyloid had an M-protein on SPEP compared to 7 (44%) with AL amyloid. Only 2 patients with AL amyloid had M-protein greater than 5 g/L while both wATTR patients had less than 5 g/L. In those with serum free light chain testing available (wATTR n=24, AL n=16), median lambda light chain level was higher in AL patients (176.0 vs 16.9 mg/L for wtATTR, p=<0.01). No difference was seen in kappa light chains (16.5 vs 23.8 mg/L for wATTR, p=0.60), though the only patient with kappa AL amyloid had kappa light chains significantly elevated at 1640 mg/L. The kappa/lambda ratio was abnormal in 15% of wATTR patients (all kappa predominant) compared to 100% in AL amyloid patients (94% lambda predominant) (p=<0.01). The median difference between involved and uninvolved light chain (dFLC) was 22 mg/L for wtATTR patients compared to 249 mg/L for AL patients. In patients with bone marrow biopsy results available (AL n=15, wATTR n=7), bone marrow plasma cell percentage was higher in patients with AL amyloid (median 7% vs 2%, p=0.01). No monoclonal plasma cells were seen on bone marrow in wATTR patients by immunophenotype. Treatment for patients with AL amyloid wasbortezomib, cyclophosphamide, and dexamethasone (VCD) in 11 (69%); VCD followed by melphalan 200 mg/m2 autologous transplantation in 1 (6%); melphalan/dexamethasone in 1 (6%); no treatment in 2 (13%); unknown in 1 (6%). In evaluable patients, hematologic response rate was 54% (complete response n=4, very good partial response n=2, partial response n=1, no response n=6). With a median follow-up of 1.8 years for surviving patients, 1 year overall survival (OS) was 76% for the entire cohort. Patients with AL amyloidosis had significantly poorer 1 year OS (41% vs 92% for wATTR patients, p=<0.01). Patients with NYHA class 3-4 had significantly worse 1 year OS (54% vs 96% for those 1-2, p=<0.01), and this held true for both AL and wATTR patients. In AL patients, revised Mayo stage (Kumar et al, JCO 2012) of III-IV predicted for poor 1 year OS (19% vs 75% for stages I-II, p=0.03), as did not achieving complete response to primary treatment (1 year OS 33% vs 67% for CR patients, p=0.06).DISCUSSION & CONCLUSIONS: Male sex, older age, and lower LVEF were more common in patients with wATTR compared to AL amyloidosis. Higher levels of BNP, larger dFLC with lambda predilection, and higher bone marrow plasma cell percentage were more common in AL amyloid patients. Overall survival was significantly worse for patients with AL amyloidosis, particularly those with high NHYA class, advanced revised Mayo stage, and suboptimal response to primary therapy. These results highlight the importance of accurate amyloid sub-typing in patients with suspected cardiac amyloidosis. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.