Monoclonal B-cell lymphocytosis (MBL), CD4(+)/CD8(weak) T-cell large granular lymphocytic leukemia (T-LGL leukemia) and monoclonal gammopathy of unknown significance (MGUS): molecular and flow cytometry characterization of three concomitant hematological disorders

The diagnosis of T-cell large granular lymphocytic leukemia in association with other B-cell disorders is uncommon but not unknown. However, the concomitant presence of three hematological diseases is extraordinarily rare. We report an 88-year-old male patient with three simultaneous clonal disorders, that is, CD4+/CD8(weak) T-cell large granular lymphocytic leukemia, monoclonal gammopathy of unknown significance and monoclonal B-cell lymphocytosis. The patient has only minimal complaints and has no anemia, neutropenia or thrombocytopenia. Lymphadenopathy and hepatosplenomegaly were not present. The three disorders were characterized by flow cytometry analysis, and the clonality of the T-cell large granular lymphocytic leukemia was confirmed by polymerase chain reaction. Interestingly, the patient has different B-cell clones, given that plasma cells of monoclonal gammopathy of unknown significance exhibited a kappa light-chain restriction population and, on the other hand, B-lymphocytes of monoclonal B-cell lymphocytosis exhibited a lambda light-chain restriction population. This finding does not support the antigen-driven hypothesis for the development of multi-compartment diseases, but suggests that T-cell large granular lymphocytic expansion might represent a direct antitumor immunological response to both B-cell and plasma-cell aberrant populations, as part of the immune surveillance against malignant neoplasms.

Sporadic late-onset nemaline myopathy with MGUS: long-term follow-up after melphalan and SCT.

OBJECTIVE Sporadic late-onset nemaline myopathy (SLONM) is a rare, late-onset myopathy that progresses subacutely. If associated with a monoclonal gammopathy of unknown significance (MGUS), the outcome is unfavorable: the majority of these patients die within 1 to 5 years of respiratory failure. This study aims to qualitatively assess the long-term treatment effect of high-dose melphalan (HDM) followed by autologous stem cell transplantation (SCT) in a series of 8 patients with SLONM-MGUS. METHODS We performed a retrospective case series study (n = 8) on the long-term (1-8 years) treatment effect of HDM followed by autologous SCT (HDM-SCT) on survival, muscle strength, and functional capacities. RESULTS Seven patients showed a lasting moderate-good clinical response, 2 of them after the second HDM-SCT. All of them had a complete, a very good partial, or a partial hematologic response. One patient showed no clinical or hematologic response and died. CONCLUSIONS This case series shows the positive effect of HDM-SCT in this rare disorder. Factors that may portend an unfavorable outcome are a long disease course before the hematologic treatment and a poor hematologic response. Age at onset, level and type of M protein (κ vs λ), and severity of muscle weakness were not associated with a specific outcome. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with SLONM-MGUS, HDM-SCT increases the probability of survival and functional improvement.

Insights into the multistep transformation of MGUS to myeloma using microarray expression analysis.

To define specific pathways important in the multistep transformation process of normal plasma cells (PCs) to monoclonal gammopathy of uncertain significance (MGUS) and multiple myeloma (MM), we have applied microarray analysis to PCs from 5 healthy donors (N), 7 patients with MGUS, and 24 patients with newly diagnosed MM. Unsupervised hierarchical clustering using 125 genes with a large variation across all samples defined 2 groups: N and MGUS/MM. Supervised analysis identified 263 genes differentially expressed between N and MGUS and 380 genes differentially expressed between N and MM, 197 of which were also differentially regulated between N and MGUS. Only 74 genes were differentially expressed between MGUS and MM samples, indicating that the differences between MGUS and MM are smaller than those between N and MM or N and MGUS. Differentially expressed genes included oncogenes/tumor-suppressor genes (LAF4, RB1, and disabled homolog 2), cell-signaling genes (RAS family members, B-cell signaling and NF-kappaB genes), DNA-binding and transcription-factor genes (XBP1, zinc finger proteins, forkhead box, and ring finger proteins), and developmental genes (WNT and SHH pathways). Understanding the molecular pathogenesis of MM by gene expression profiling has demonstrated sequential genetic changes from N to malignant PCs and highlighted important pathways involved in the transformation of MGUS to MM.

Monoclonal Gammopathy of Undetermined Significance and Multiple Myeloma in Older Adults.

Multiple myeloma (MM) and monoclonal gammopathy of undetermined significance (MGUS) are plasma cell disorders of aging. The landscape of the diagnosis and management of MM and MGUS are rapidly changing. This article provides an updated understanding of the clinical presentation, evaluation, diagnosis, and management of older adults with MM and MGUS. Because most oncology providers are not formally trained in geriatric medicine, geriatricians play a key role in providing oncologists with a broader understanding of patient health status in the hope of improving outcomes for older adults with MM.

Prior Autoimmune Disease and Risk of Monoclonal Gammopathy of Undetermined Significance and Multiple Myeloma:A Systematic Review

Background: Several observational studies have investigated autoimmune disease and subsequent risk of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma. Findings have been largely inconsistent and hindered by the rarity and heterogeneity of the autoimmune disorders investigated. A systematic review of the literature was undertaken to evaluate the strength of the evidence linking prior autoimmune disease and risk of MGUS/multiple myeloma.

Methods: A broad search strategy using key terms for MGUS, multiple myeloma, and 50 autoimmune diseases was used to search four electronic databases (PubMed, Medline, Embase, and Web of Science) from inception through November 2011.

Results: A total of 52 studies met the inclusion criteria, of which 32 were suitably comparable to perform a meta-analysis. “Any autoimmune disorder” was associated with an increased risk of both MGUS [n = 760 patients; pooled relative risk (RR) 1.42; 95% confidence interval (CI), 1.14–1.75] and multiple myeloma (n>2,530 patients; RR 1.13, 95% CI, 1.04–1.22). This risk was disease dependent with only pernicious anemia showing an increased risk of both MGUS (RR 1.67; 95% CI, 1.21–2.31) and multiple myeloma (RR 1.50; 95% CI, 1.25–1.80).

Conclusions: Our findings, based on the largest number of autoimmune disorders and patients with MGUS/multiple myeloma reported to date, suggest that autoimmune diseases and/or their treatment may be important in the etiology of MGUS/multiple myeloma. The strong associations observed for pernicious anemia suggest that anemia seen in plasma cell dyscrasias may be of autoimmune origin.

Impact: Underlying mechanisms of autoimmune diseases, general immune dysfunction, and/or treatment of autoimmune diseases may be important in the pathogenesis of MGUS/multiple myeloma. Cancer Epidemiol Biomarkers Prev; 23(2); 332–42. ©2014 AACR.

Fatores de risco para a progressão da gamapatia monoclonal de significado indeterminado para mieloma múltiplo

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Intraclonal heterogeneity is a critical early event in the development of myeloma and precedes the development of clinical symptoms.

The mechanisms involved in the progression from monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma (SMM) to malignant multiple myeloma (MM) and plasma cell leukemia (PCL) are poorly understood but believed to involve the sequential acquisition of genetic hits. We performed exome and whole-genome sequencing on a series of MGUS (n=4), high-risk (HR)SMM (n=4), MM (n=26) and PCL (n=2) samples, including four cases who transformed from HR-SMM to MM, to determine the genetic factors that drive progression of disease. The pattern and number of non-synonymous mutations show that the MGUS disease stage is less genetically complex than MM, and HR-SMM is similar to presenting MM. Intraclonal heterogeneity is present at all stages and using cases of HR-SMM, which transformed to MM, we show that intraclonal heterogeneity is a typical feature of the disease. At the HR-SMM stage of disease, the majority of the genetic changes necessary to give rise to MM are already present. These data suggest that clonal progression is the key feature of transformation of HR-SMM to MM and as such the invasive clinically predominant clone typical of MM is already present at the SMM stage and would be amenable to therapeutic intervention at that stage.

Deletions of CDKN2C in Multiple Myeloma: Biological and Clinical Implications

Purpose: Deletions of chromosome 1 have been described in 7% to 40% of cases of myeloma with inconsistent clinical consequences. CDKN2C at 1p32.3 has been identified in myeloma cell lines as the potential target of the deletion. We tested the clinical impact of 1p deletion and used high-resolution techniques to define the role of CDKN2C in primary patient material.Experimental Design: We analyzed 515 cases of monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM), and newly diagnosed multiple myeloma using fluorescence in situ hybridization (FISH) for deletions of CDKN2C. In 78 myeloma cases, we carried out Affymetrix single nucleotide polymorphism mapping and U133 Plus 2.0 expression arrays. In addition, we did mutation, methylation, and Western blotting analysis.Results: By FISH we identified deletion of 1p32.3 (CDKN2C) in 3 of 66 MGUS (4.5%), 4 of 39 SMM (10.3%), and 55 of 369 multiple myeloma cases (15%). We examined the impact of copy number change at CDKN2C on overall survival (OS), and found that the cases with either hemizygous or homozygous deletion of CDKN2C had a worse OS compared with cases that were intact at this region (22 months versus 38 months; P = 0.003). Using gene mapping we identified three homozygous deletions at 1p32.3, containing CDKN2C, all of which lacked expression of CDKN2C. Cases with homozygous deletions of CDKN2C were the most proliferative myelomas, defined by an expression-based proliferation index, consistent with its biological function as a cyclin-dependent kinase inhibitor.Conclusions: Our results suggest that deletions of CDKN2C are important in the progression and clinical outcome of myeloma.

Integration of global SNP-based mapping and expression arrays reveals key regions, mechanisms, and genes important in the pathogenesis of multiple myeloma.

Multiple myeloma is characterized by genomic alterations frequently involving gains and losses of chromosomes. Single nucleotide polymorphism (SNP)-based mapping arrays allow the identification of copy number changes at the sub-megabase level and the identification of loss of heterozygosity (LOH) due to monosomy and uniparental disomy (UPD). We have found that SNP-based mapping array data and fluorescence in situ hybridization (FISH) copy number data correlated well, making the technique robust as a tool to investigate myeloma genomics. The most frequently identified alterations are located at 1p, 1q, 6q, 8p, 13, and 16q. LOH is found in these large regions and also in smaller regions throughout the genome with a median size of 1 Mb. We have identified that UPD is prevalent in myeloma and occurs through a number of mechanisms including mitotic nondisjunction and mitotic recombination. For the first time in myeloma, integration of mapping and expression data has allowed us to reduce the complexity of standard gene expression data and identify candidate genes important in both the transition from normal to monoclonal gammopathy of unknown significance (MGUS) to myeloma and in different subgroups within myeloma. We have documented these genes, providing a focus for further studies to identify and characterize those that are key in the pathogenesis of myeloma.

Immunoglobulin heavy chain sequence analysis in Waldenstrom's macroglobulinemia and immunoglobulin M monoclonal gammopathy of undetermined significance.

In this study, we used IGH sequence analysis to assess the maturational status of Waldenstrom's (WM) macroglobulinemia and its putative precursor immunoglobulin (Ig)-M monoclonal gammopathy of undetermined significance (MGUS). IGH sequence analysis was performed using standard methods in 23 cases (20 WM and 3 IgM MGUS as defined by consensus panel criteria). Waldenstrom's macroglobulinemia cases were characterized by heavily mutated IGH genes (median, 6.3%; range, 3.8%-13.9%) but without intraclonal variation (ICV). IgM MGUS was similarly characterized by somatic hypermutation (median, 7.5%; range, 7%-7.7%), but ICV was evident in 1 of the 3 cases. We would therefore conclude that WM is characterized by somatic hypermutation without ICV, which supports a derivation from postgerminal center/memory B cells. IgM MGUS is also characterized by somatic hypermutation but, in a manner similar to IgA/IgG MGUS, can be associated with ICV, although the significance of this remains unclear.

Avaliação do papel dos polimorfismos em enzimas metabolizadoras e enzimas transportadoras de fármacos em neoplasias hematológicas

O cancro é um dos maiores causadores globais de mortalidade e morbilidade, ocorrendo cerca de 14 milhões de novos casos por ano e 8,2 milhões de mortes anuais com esta patologia, números que tendem a aumentar 70% nas próximas duas décadas. A característica tumoral mais nefasta é a sua capacidade de metastização para outros órgãos, um mecanismo que pode ser despoletado pela falha dos mecanismos normais de controlo de crescimento, proliferação e reparação celulares, que facilita o processo de transformação de células normais em células cancerígenas. A oncogénese processa-se em três etapas, a iniciação, a promoção e a progressão e pode ter origem em células estaminais cancerígenas, que regulam as capacidades de propagação e recidiva do tumor. As neoplasias hematológicas resultam de alterações genéticas e /ou epigenéticas que conduzem à desregulação da proliferação, ao bloqueio da diferenciação e/ou à resitência à apoptose. Para além dos fatores de risco exógenos, como agentes carcinogénicos físicos, químicos e biológicos, existem também fatores endógenos, incluindo características genéticas, que podem alterar a predisposição para o aparecimento de neoplasias, bem como influenciar a resposta à terapêutica. Uma das terapêuticas aplicadas no tratamento do cancro é a quimioterapia. Os fármacos administrados a doentes oncológicos seguem normalmente o percurso de absorção, distribuição, metabolização e eliminação. Este curso pode sofrer alterações caso as proteínas transportadoras e metabolizadoras necessárias não atuem corretamente. Para um melhor conhecimento da influência das alterações provocadas por variações nos genes que codificam proteínas transportadoras de efluxo (MDR1, MRP1), proteínas de influxo (OCTN2) e proteínas metabolizadoras (UCK2), o objetivo deste trabalho consistiu na avaliação de polimorfismos nos genes MDR1, MRP1, OCTN2 e UCK2 e da sua relação com a predisposição para o desenvolvimento de neoplasias hematológicas. Para isto, foram utilizadas amostras de 307 doentes com neoplasias hematológicas, 83 de Síndrome Mielodisplásica (SMD), 63 Leucemia Mieloide Aguda (LMA), 16 de Síndrome Mielodisplásica/Neoplasias Mieloproliferativas (SMD/NMP), 77 de Mieloma Múltiplo (MM) e 68 de Gamapatia Monoclonal de Significado Indeterminado (MGUS) e 164 de controlos não neoplásicos e/ou indivíduos saudáveis. As amostras de ADN foram extraídas do sangue periférico com protocolo adequado. De forma a determinar os genótipos correspondentes a cada amostra, realizaram-se técnicas de RFLP-PCR e ARMS-PCR. Posteriormente, calcularam-se estatisticamente as frequências alélicas e genotípicas relativas às variantes polimórficas dos genes MDR1, MRP1, OCTN2 e UCK2 e verificou-se se estavam em Equilíbrio de Hardy-Weinberg. De seguida, avaliou-se a força de associação entre as formas polimórficas e o risco de desenvolvimento de neoplasias hematológicas, através do cálculo do risco relativo por análise de regressão logística. Avaliaram-se ainda os perfis genéticos e a possível relação com o desenvolvimento e progressão da neoplasia com recurso a regressão logística e análise de Kaplan-Meier. De um modo geral as frequências alélicas e genotípicas não se revelaram alteradas comparativamente ao esperado. A análise do odds ratio associado ao polimorfismo rs1045642 do gene MDR1 revelou que o genótipo CT pode constituir um fator de risco aumentado de 1,84x para o desenvolvimento de Gamapatias Monoclonais e 2,27x para o desenvolvimento de Mieloma Múltiplo. Por outro lado, a presença de genótipos portadores do alelo T têm um efeito protetor no desenvolvimento de MM (OR=0,41). O cálculo do risco associado ao polimorfismo rs4148330 do gene MRP1 revela que o genótipo AG é um fator protetor (OR=0,50) para o desenvolvimento de LMA, assim como o alelo G (OR=0,50). Além disso, verificámos que existe uma associação de risco de desenvolver neoplasia com o polimorfismo rs2185268 do gene UCK2. De facto, a presença dos genótipos CC e AC representam um fator de risco 4,59x aumentado para o desenvolvimento de SMD/NMP. O polimorfismo rs274561 do gene OCTN2 não apresenta relação com o risco relativo de desenvolvimento neoplásico. Da avaliação da influência dos polimorfismos em estudo na sobrevivência global dos doentes, podemos assumir que a presença do genótipo GG relativo ao polimorfismo rs2185268 do gene UCK2 representa uma diminuição da sobrevivência em 11 meses. Os resultados obtidos a partir do nosso estudo permitem-nos concluir que os polimorfismos podem ser fatores relevantes na predisposição para o desenvolvimento de neoplasias hematológicas e na progressão destas doenças.

Multiple myeloma and bone

International audience

Factors associated with an increased risk of vertebral fracture in monoclonal gammopathies of undetermined significance

International audience