Lymphoplasmacytic Lymphoma

C H A P T E R

87 

WALDENSTRÖM MACROGLOBULINEMIA/ LYMPHOPLASMACYTIC LYMPHOMA Steven P. Treon, Jorge J. Castillo, Zachary R. Hunter, and Giampaolo Merlini

Waldenström macroglobulinemia (WM) is a lymphoid neoplasm resulting from the accumulation, predominantly in the marrow, of a clonal population of lymphocytes, lymphoplasmacytic cells, and plasma cells, which secrete a monoclonal immunoglobulin (Ig) M.1 WM corresponds to lymphoplasmacytic lymphoma (LPL) as defined in the Revised European-American Lymphoma (REAL) and World Health Organization classification systems.2,3 Most cases of LPL are WM; less than 5% of cases are IgA-secreting, IgG-secreting, or nonsecreting LPL. In 1944, Jan Waldenström, a Swedish physician-scientist, reported in Acta Medica Scandinavica three cases of a disease he presciently thought was related to myeloma but for the absence of bone involvement and the scarcity of plasma cells in the infiltrate of small lymphocytes. He noted the increase in plasma protein concentration, marked increased serum viscosity, exaggerated bleeding and retinal hemorrhages, and virtually every other feature of the disorder in his case descriptions. In collaboration with a colleague, he showed, using ultracentrifugation and electrophoresis, that the abundant abnormal protein had a molecular weight of approximately 1 million and was not an aggregate of smaller proteins. The disease, which he described with such thoroughness, was later named in his honor.

EPIDEMIOLOGY The age-adjusted incidence rate of WM in the United States is 3.4 per 1 million among males and 1.7 per 1 million among females. It increases in incidence geometrically with age.4,5 The incidence rate is higher among Americans of European descent. Americans of African descent represent approximately 5% of all patients. Genetic factors play a role in the pathogenesis of WM. Approximately 20% of patients with WM are of Ashkenazi Jewish ethnic background.6 Familial disease has been reported commonly, including multigenerational clustering of WM and other B-cell lymphoproliferative diseases.7–10 Approximately 20% of 257 sequential patients with WM presenting to a tertiary referral center had a first-degree relative with either WM or another B-cell disorder.9 Familial clustering of WM with other immunologic disorders, including hypogammaglobulinemia and hypergammaglobulinemia (particularly polyclonal IgM), autoantibody production (particularly to the thyroid), and manifestation of hyperactive B cells, has also been reported in relatives without WM.9,10 Increased expression of the BCL2 gene with enhanced survival has been observed in B cells from familial patients and their family members.10 The role of environmental factors is uncertain; however, but chronic antigenic stimulation from infections and certain drug or chemical exposures have been considered but have not reached a level of scientific certainty. Hepatitis C virus (HCV) infection was implicated in WM causality in some series, but no association was found in a study of 100 consecutive patients with WM in whom serologic and molecular diagnostic studies for HCV infection were performed.11–13

PATHOGENESIS Nature of the WM Clone Examination of the B-cell clone(s) found in the bone marrow (BM) of patients with WM reveals a range of differentiation, from small lymphocytes with large focal deposits of surface immunoglobulins, to lymphoplasmacytic cells, to mature plasma cells that contain intracytoplasmic IgM (Fig. 87.1).14 Circulating clonal B cells are often detectable in patients with WM, though lymphocytosis is uncommon.15,16 WM cells express the monoclonal IgM, and some clonal cells also express surface IgD.17 The characteristic immunophenotypic profile of WM lymphoplasmacytic cells includes the expression of the pan–B-cell markers CD19, CD20 (including FMC7), CD22, and CD79.17,18 Expression of CD5, CD10, and CD23 can be present in 10% to 20% of cases, and their presence does not exclude the diagnosis of WM.19 In addition, multiparameter flow cytometric analysis has also identified CD25 and CD27 as being characteristic of the WM clone, and that a CD22dim/CD25+/CD27+/ IgM+ population can be observed among clonal B lymphocytes in patients with IgM monoclonal gammopathy of undetermined significance (MGUS) who ultimately progress to WM.20 Somatic mutations in immunoglobulin genes are present with increased frequency of nonsynonymous versus silent mutations in complementarity-determining regions, along with somatic hypermutation, thereby supporting a postgerminal center derivation for the WM B-cell clone in most patients.21,22 A strong preferential use of VH3/JH4 gene families without intraclonal variation, and without evidence for any isotype-switched transcripts, has also been shown.23,24 Taken together, these data support an IgM+ and/or IgM+IgD+ memory B-cell origin for most cases of WM. In contrast to myeloma plasma cells, no recurrent translocations have been described in WM, which can help to distinguish IgM myeloma cases that often exhibit t11;14 translocations from WM.25,26 Despite the absence of IgH translocations, recurrent chromosomal abnormalities are present in WM cells. These include deletions in chromosome 6q21–23 in 40% to 60% of patients with WM, with concordant gains in 6p in 41% of patients with 6q deletion.27–30 In a series of 174 untreated patients with WM, 6q deletions, followed by trisomy 18, 13q deletions, 17p deletions, trisomy 4, and 11q deletions, were observed.30 Deletion of 6q and trisomy 4 were associated with an adverse prognosis in this series. Because 6q deletions represent the most recurrent cytogenetic finding in WM cases, there has been great interest in identifying the region of minimal deletion and possible target genes within this region. Two putative gene candidates within this region include TNFAIP3, a negative regulator of nuclear factor-κB signaling (NFκB), and PRDM1, a master regulator of B-cell differentiation.29,31 The removal of an NFκB-negative regulator is of particular interest because the phosphorylation and translocation of NFκB into the nucleus is a crucial event for WM cell survival.32 The success of proteasome inhibitor therapy in WM has been postulated to occur because the degradation of negative regulators of NFκB, such as inhibitor of κ B (IκB), is blocked.33,34 1419

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MUTATION IN MYD88 A highly recurrent somatic mutation (MYD88L265P) was first identified in patients with WM by whole genome sequencing (WGS) and confirmed by multiple studies through Sanger sequencing and/or allele-specific polymerase chain reaction (PCR) assays.35–40 MYD88L265P is expressed in 90% to 95% of WM cases when more sensitive allele-specific PCR is employed using both CD19-sorted and unsorted BM cells.36–40 By comparison, MYD88L265P was absent in myeloma samples, including IgM myeloma, and was expressed in a small subset (6% to 10%) of patients with marginal zone lymphoma, who surprisingly have WM-related features.36–38,41 By PCR assays, 50% to 80% of patients with IgM MGUS also express MYD88L265P, and expression of this mutation was associated with increased risk for malignant progression.36–38,42 The presence of MYD88L265P in patients with IgM MGUS suggests a role for this mutation as an early oncogenic driver, and other mutations and/or copy number alterations leading to abnormal gene expression are likely to promote disease progression.29 The impact of MYD88L265P to growth and survival signaling in WM cells has been addressed in several studies (Fig. 87.2). Knockdown of MYD88 decreased survival of MYD88L265P-expressing WM cells, whereas survival was enhanced by knock-in of MYD88L265P versus wild-type (WT) MYD88.43 The discovery of a mutation in MYD88

Fig. 87.1  MARROW FILM FROM A PATIENT WITH WALDENSTRÖM MACROGLOBULINEMIA. Note infiltrate of mature lymphocytes, lymphoplasmacytic cells, and plasma cells. (Used with permission from Marvin J. Stone, MD.)

TLR4

CXCR4

IL1R

TIRAP L265P

BTK P

P

P

L265P

MYD88

MYD88

IR

P

AK IR 4 AK 1

P

TAK1

PI3Kδ

4 AK IR 1 AK IR P

NONSENSE AND FRAMESHIFT CXCR4 WHIM MUTATIONS

TRAF6 AKT

P P

NEMO IKKα

IKKβ IKBα

HIVEP2

P

P P

P ERK P

p50

TNFAIP3

MEK P

p65 NFkB

SURVIVAL

Fig. 87.2  MYD88L265P AND CXCR4WHIM MUTATIONS ARE HIGHLY PREVALENT IN PATIENTS WITH WALDENSTRÖM MACROGLOBULINEMIA AND TRIGGER TRANSCRIPTIONAL FACTORS THAT INCLUDE NFκB, AKT, AND ERK THAT SUPPORT THE GROWTH AND SURVIVAL OF LYMPHOPLASMACYTIC CELLS. BTK, Bruton’s tyrosine kinase; CXCR4, C-X-C chemokine receptor type 4; ERK, Extracellular signal-regulated kinase; HIVEP2, human immunodeficiency virus type I enhancer binding protein 2; IKBα, nuclear factor of κ light polypeptide gene enhancer in B cells inhibitor α; IKK, inhibitor of nuclear factor-κB kinase; IL1R, interleukin-1 receptor; IRAK, interleukin receptor-associated kinase; MEK, mitogen-activated protein kinase kinase; NEMO, nuclear factor-κB essential modulator; NFκB, nuclear factor-κB; PI3Kδ, phosphoinositide 3-kinase δ; TAK1, transforming growth factor β-activated kinase 1; TIRAP, Toll-interleukin 1 receptor domain-containing adaptor protein; TLR4, Toll-like receptor 4; TNFAIP3, tumor necrosis factor α-induced protein 3; TRAF6, tumor necrosis factor α receptor-associated factor 6; WHIM, warts, hypogammaglobulinemia, infections, and myelokathexis syndrome.

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma

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is of significance, given its role as an adaptor molecule in Toll-like receptor (TLR) and interleukin-1 receptor (IL-1R) signaling.44 All TLRs except for TLR3 use MYD88 to facilitate their signaling. Following TLR or IL-1R stimulation, MYD88 is recruited to the activated receptor complex as a homodimer, which then complexes with interleukin receptor-associated kinase 4 (IRAK4) and activates IRAK1 and IRAK2.45–47 Tumor necrosis factor receptor-associated factor 6 is then activated by IRAK1, leading to NFκB activation via IκBα phosphorylation.48 Use of inhibitors of the MYD88 pathway led to decreased IRAK1 and IκBα phosphorylation, as well as to survival of MYD88L265P-expressing WM cells. These observations are of particular relevance to WM because NFκB signaling is important for WM growth and survival.49 Bruton’s tyrosine kinase (BTK) is also activated by MYD88L265P.43 Activated BTK coimmunoprecipitates with MYD88, which could be abrogated by use of a BTK inhibitor, and overexpression of MYD88L265P but not WT MYD88 triggers BTK activation. Knockdown of MYD88 by lentiviral transfection or use of a MYD88 homodimerization inhibitor also abrogated BTK activation in MYD88L265P-mutated WM cells.

The importance of MYD88 and CXCR4 mutations in the clinical presentation of patients with WM was recently reported. Significantly higher BM involvement, serum IgM levels, and symptomatic disease requiring therapy, including hyperviscosity syndrome, were observed in those patients with MYD88L265PCXCR4WHIM/NS mutations.50 Patients with MYD88L265PCXCR4WHIM/FS or MYD88L265PCXCR4WT had intermediate BM and serum IgM levels; those with MYD88WTCXCR4WT showed the lowest BM disease burden. Fewer patients with MYD88L265P and CXCR4WHIM/FS or NS than with MYD88L265PCXCR4WT presented with adenopathy, further delineating differences in disease tropism based on CXCR4 status. Despite the more aggressive presentation associated with CXCR4WHIM/NS genotype, risk of death was not impacted by CXCR4 mutation status. Risk of death was found to be 10-fold higher in patients with the MYD88WT versus the MYD88L265P genotype.50

CXCR4 WHIM MUTATIONS

MARROW MICROENVIRONMENT

The second most common somatic mutation after MYD88L265P revealed by WGS was found in the C-terminus of the C-X-C chemokine receptor type 4 (CXCR4) receptor. These mutations are present in 30% to 35% of patients with WM, and they impact serine phosphorylation sites that regulate CXCR4 signaling by its only known ligand, SDF-1α (CXCL12).29,50–52 The location of somatic mutations found in the C-terminus of CXCR4 in WM are similar to those observed in the germline of patients with WHIM (warts, hypogammaglobulinemia, infections, and myelokathexis) syndrome, a congenital immunodeficiency disorder characterized by chronic noncyclic neutropenia.53 Patients with WHIM syndrome exhibit impaired CXCR4 receptor internalization following SDF-1α stimulation, which results in persistent CXCR4 activation and myelokathexis.54 In patients with WM, two classes of CXCR4 mutations occur in the C-terminus. These include nonsense (CXCR4WHIM/NS) mutations that truncate the distal 15– to 20–amino acid region and frameshift (CXCR4WHIM/FS) mutations that comprise a region of up to 40 amino acids in the C-terminal domain.29,50 Nonsense and frameshift mutations are almost equally divided among patients with WM with CXCR4 somatic mutations, and over 30 different types of CXCR4WHIM mutations have been identified in patients with WM.29,50 Preclinical studies with WM cells engineered to express nonsense and frameshift CXCR4WHIM-mutated receptors have shown enhanced and sustained AKT and extracellular signal-regulated kinase signaling following SDF-1α relative to CXCR4WT (Fig. 87.2), as well as increased cell migration, adhesion, growth, and survival, and also drug resistance of WM cells.51,55,56

In patients with WM, increased numbers of mast cells are found in the BM, where they are usually admixed with tumor cell aggregates (Fig. 87.3).14,18,57 The role of mast cells in WM has been investigated in one study in which coculture of primary autologous or mast cell lines with WM lymphoplasmacytic cells resulted in dose-dependent WM cell proliferation and/or tumor colony formation through CD40 ligand (CD40L) signaling.57 WM cells release soluble CD27 (sCD27), which may be triggered by cleavage of membrane bound CD27 by matrix metalloproteinase 8.58 sCD27 levels are elevated in the serum of patients with WM and follow disease burden in mice engrafted with WM cells, as well as in patients with WM.59 sCD27 triggers the upregulation of CD40L as well as a proliferation-inducing ligand on mast cells derived from patients with WM, as well as mast cell lines through its receptor CD70. Modeling in mice treated with a CD70-blocking antibody shows inhibition of tumor cell growth,

IMPACT OF WM GENOMICS ON CLINICAL PRESENTATION

Other Somatic Events Many copy number alterations have been revealed in patients with WM that impact growth and survival pathways. Frequent loss of HIVEP2 (80%) and TNAIP3 (50%) genes that are negative regulators of NFκB expression (Fig. 87.2), as well as LYN (70%) and IBTK (40%) that modulate B-cell receptor signaling have been revealed by WGS.29 WGS has also revealed common defects in chromatin remodeling, with somatic mutations in ARID1A present in 17% and loss of ARID1B in 70% of patients with WM. Both ARID1A and ARID1B are members of the SWI/SNF family of proteins, and they are thought to exert their effects via p53 and cyclin-dependent kinase inhibitor 1A regulation. TP53 is mutated in 7% of sequenced WM genomes, whereas PRDM2 and TOP1 that participate in TP53related signaling are deleted in 80% and 60% of patients with WM, respectively.29 Taken together, somatic events that contribute to impaired DNA damage response are also common in WM.

Fig. 87.3  FUNDUSCOPIC EXAMINATION OF A PATIENT WITH WALDENSTRÖM MACROGLOBULINEMIA WITH HYPERVISCOSITY-RELATED CHANGES, INCLUDING DILATED RETINAL VESSELS, HEMORRHAGES, AND “VENOUS SAUSAGING.” The white material at the edge of the veins may be cryoglobulin. (Used with permission from Marvin J. Stone, MD.)

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suggesting that WM cells require a microenvironmental support system for their growth and survival.60 High levels of CXCR4 and very late antigen-4 (VLA-4) are expressed by WM cells.59 In blocking experiment studies, CXCR4 was shown to support migration of WM cells, whereas VLA-4 contributed to adhesion of WM cells to BM stromal cells.59

CLINICAL FEATURES Table 87.1 provides the clinical and laboratory features at the time of diagnosis of patients with WM in one large institutional study.16

TABLE 87.1

Clinical and Laboratory Findings for 356 Consecutive Newly Diagnosed Patients With Waldenström Macroglobulinemia Median

Normal Reference Range

Range

Age (years)

58

Sex (male/female)

215/141

Marrow involvement (% of area on slide)

30

Adenopathy (% of patients)

15

NA

Splenomegaly (% of patients)

10

NA

IgM (mg/dL)

2620

270–12,400

40–230

IgG (mg/dL)

674

80–2770

700–1600

IgA (mg/dL)

58

6–438

70–400

Serum viscosity (cp)

2.0

1.1–7.2

1.4–1.9

Hematocrit (%)

35

17–45

35–44

9

32–91

NA NA

5–95

NA

Platelet count (×10 /L)

275

42–675

155–410

White cell count (×109/L)

6.4

1.7–22

3.8–9.2

β2-M (mg/dL)

2.5

0.9–13.7

0–2.7

LDH (U/mL)

313

61–1701

313–618

β2M, β2-Microglobulin; cp, centipoise; Ig, immunoglobulin; LDH, lactate dehydrogenase; NA, not applicable. Data from patients seen at the Dana-Farber Cancer Institute, Boston, MA.

TABLE 87.2

Unlike most indolent lymphomas, splenomegaly and lymphadenopathy are uncommon (≤15%). Purpura is frequently associated with cryoglobulinemia and in rare circumstances with light-chain (AL) amyloidosis. Hemorrhagic and neuropathic manifestations are multifactorial (see “IgM-Related Neuropathy” section below). The morbidity associated with WM is caused by the co-occurrence of two main components: tissue infiltration by neoplastic cells and, importantly, the physicochemical and immunologic properties of the monoclonal IgM. As shown in Table 87.2, the monoclonal IgM can produce clinical manifestations through several different mechanisms related to its physicochemical properties, nonspecific interactions with other proteins, antibody activity, and tendency to deposit in tissues.61–63

MORBIDITY MEDIATED BY THE EFFECTS OF IGM Hyperviscosity Syndrome The increased plasma IgM levels lead to increased blood hyperviscosity and its complications.64 The mechanisms behind the marked increase in the resistance to blood flow and the resulting impaired transit through the microcirculatory system are complex.64–67 The main determinants are (1) a high concentration of monoclonal IgMs, which may form aggregates and may bind water through their carbohydrate component; and (2) the interaction of IgMs with blood cells. Monoclonal IgM increases red cell aggregation (rouleau formation) and red cell internal viscosity while reducing red cell deformability. The presence of cryoglobulins contributes to increasing blood viscosity, as well as to the tendency to induce erythrocyte aggregation. Serum viscosity is proportional to the IgM concentration up to 30 g/L, then increases sharply at higher levels. Increased plasma viscosity may also contribute to inappropriately low erythropoietin production, which is the major reason for anemia in these patients.67 Renal synthesis of erythropoietin is inversely correlated with plasma viscosity. Clinical manifestations are related to circulatory disturbances that can best be appreciated by ophthalmoscopy, which shows distended and tortuous retinal veins, hemorrhages, and papilledema (Fig. 87.4).68 Symptoms usually occur when the monoclonal IgM concentration exceeds 50 g/L or when serum viscosity is greater than 4.0 centipoises (cp), but there is individual variability, with some patients showing no evidence of hyperviscosity even at 10 cp.64 The most common symptoms are oronasal mucosal bleeding, visual disturbances because of retinal bleeding, and dizziness that

Physicochemical and Immunologic Properties of the Monoclonal Immunoglobulin M Protein in Waldenström Macroglobulinemia

Properties of IgM Monoclonal Protein

Diagnostic Condition

Clinical Manifestations

Pentameric structure

Hyperviscosity

Headaches, blurred vision, epistaxis, retinal hemorrhages, leg cramps, impaired mentation, intracranial hemorrhage

Precipitation on cooling

Cryoglobulinemia (type I)

Raynaud phenomenon, acrocyanosis, ulcers, purpura, cold urticaria

Autoantibody activity to myelin-associated glycoprotein, ganglioside M1, sulfatide moieties on peripheral nerve sheaths

Peripheral neuropathies

Sensorimotor neuropathies, painful neuropathies, ataxic gait, bilateral foot drop

Autoantibody activity to IgG

Cryoglobulinemia (type II)

Purpura, arthralgia, renal failure, sensorimotor neuropathies

Autoantibody activity to red blood cell antigens

Cold agglutinins

Hemolytic anemia, Raynaud phenomenon, acrocyanosis, livedo reticularis

Tissue deposition as amorphous aggregates

Organ dysfunction

Skin: bullous skin disease, papules, Schnitzler syndrome Gastrointestinal: diarrhea, malabsorption, bleeding Kidney: proteinuria, renal failure (light-chain component)

Tissue deposition as amyloid fibrils (light-chain component most commonly)

Organ dysfunction

Fatigue, weight loss, edema, hepatomegaly, macroglossia, organ dysfunction of involved organs (heart, kidney, liver, peripheral sensory and autonomic nerves)

IgM, Immunoglobulin M.

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A

B Fig. 87.4  CRYOGLOBULINEMIA MANIFESTING WITH SEVERE ACROCYANOSIS IN A PATIENT WITH WALDENSTRÖM MACROGLOBULINEMIA (A) BEFORE AND (B) FOLLOWING WARMING AND PLASMAPHERESIS.

rarely may lead to stupor or coma. Heart failure can be aggravated, particularly in the elderly, owing to increased blood viscosity, expanded plasma volume, and anemia. Inappropriate red cell transfusions can exacerbate hyperviscosity and may precipitate cardiac failure.

Cryoglobulinemia The monoclonal IgM can behave as a type I cryoglobulin in up to 20% of patients, and it leads to no symptoms in most cases.16,64,69,70 Cryoprecipitation is dependent mainly on the concentration of monoclonal IgM; for this reason, plasmapheresis or plasma exchange is commonly effective in this condition. Symptoms result from impaired blood flow in small vessels and include Raynaud phenomenon; acrocyanosis; necrosis of the regions most exposed to cold, such as the tips of the nose, ears, fingers, and toes (Fig. 87.5); malleolar ulcers; purpura; and cold urticaria. Renal manifestations are infrequent. Mixed cryoglobulins (type II) consisting of IgM-IgG complexes may be associated with HCV infection.70 Autoantibody Activity.  Monoclonal IgM may exert its pathogenic effects through specific recognition of autologous antigens, the most notable being nerve constituents, immunoglobulin determinants, and red blood cell antigens. IgM-Related Neuropathy.  IgM-related peripheral neuropathy is common in patients with WM, with estimated prevalence rates of 5% to 40%.71–73 Approximately 8% of idiopathic neuropathies are associated with a monoclonal gammopathy, with a preponderance of IgM (60%), followed by IgG (30%) and IgA (10%).74,75 The nerve damage is mediated by diverse pathogenetic mechanisms: (1) IgM antibody activity toward nerve constituents causing demyelinating

polyneuropathies; (2) endoneurial granulofibrillar deposits of IgM without antibody activity, associated with axonal polyneuropathy; (3) occasionally by tubular deposits in the endoneurium associated with IgM cryoglobulin; and, rarely, (4) amyloid deposits or neoplastic cell infiltration of nerve structures.73,76 Half of the patients with IgM neuropathy have a distinctive clinical syndrome that is associated with antibodies against a minor 100 kDa glycoprotein component of nerve known as the myelinassociated glycoprotein (MAG). Anti-MAG antibodies are generally monoclonal IgMκ and usually also exhibit reactivity with other glycoproteins or glycolipids that share antigenic determinants with MAG.77–79 The anti–MAG-related neuropathy is typically distal and symmetrical, affecting both motor and sensory functions; it is slowly progressive with a long period of stability.72,80 Most patients present with sensory complaints (paresthesias, aching discomfort, dysesthesias, or lancinating pains); imbalance and gait ataxia, owing to lack proprioception; and leg muscle atrophy in advanced stage. Patients with predominantly demyelinating sensory neuropathy in association with monoclonal IgM to gangliosides with disialosyl moieties, such as GD1b, GD3, GD2, GT1b, and GQ1b, have also been reported.81,82 Anti-GD1b and anti-GQ1b antibodies were associated with sensory ataxic neuropathy. These antiganglioside monoclonal IgMs present core clinical features of chronic ataxic neuropathy sometimes associated with ophthalmoplegia and/or red blood cell cold agglutinating activity. The disialosyl epitope is also present on red blood cell glycophorins, thereby accounting for the red cell cold agglutinin activity of anti-Pr2 specificity.83,84 Monoclonal IgM proteins that bind to gangliosides with a terminal trisaccharide moiety, including ganglioside M2 and GalNac-GD1A, are associated with chronic demyelinating neuropathy and severe sensory ataxia, unresponsive to glucocorticoids.85 Antiganglioside IgM proteins may also cross-react with lipopolysaccharides of Campylobacter jejuni, an infection known to precipitate the Miller Fisher syndrome, a variant of Guillain-Barré

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Part VII  Hematologic Malignancies

A

B

Fig. 87.5  MARROW CLOT SECTION. (A) Tryptase-staining mast cells surrounding a nodule of lymphoplasmacytic cells in a patient with Waldenström macroglobulinemia. (B) Mast cells in the same section exhibit strong CD40 ligand signaling, which has been shown to support (at least in part) the growth and survival of lymphoplasmacytic cells.

syndrome.86 Thus molecular mimicry may play a role in this condition. Antisulfatide monoclonal IgM proteins, associated with sensory-sensorimotor neuropathy, have been detected in 5% of patients with IgM monoclonal gammopathy and neuropathy.87 Motor neuron disease has been reported in patients with WM and monoclonal IgM with anti-GM1 and sulfoglucuronyl paragloboside activity.88 Polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (the POEMS syndrome) are rare in patients with WM.89 Cold Agglutinin Hemolytic Anemia.  Monoclonal IgMs may have cold agglutinin activity; they recognize specific red cell antigens at temperatures below 37°C, producing a chronic hemolytic anemia. This disorder occurs in less than 10% of patients with WM and is associated with cold agglutinin titers greater than 1 : 1000 in most cases.90 The monoclonal component is usually an IgMκ and reacts most commonly with red cell I/i antigens, resulting in complement fixation and activation.91,92 Mild to moderate chronic hemolytic anemia can be exacerbated after cold exposure. Hemoglobin levels usually remain above 70 g/L. The hemolysis is usually extravascular, mediated by removal of C3b opsonized red cells by the mononuclear phagocytes, primarily in the liver. Intravascular hemolysis from complement destruction of red blood cell membrane is infrequent. The agglutination of red cells in the skin circulation also causes Raynaud syndrome, acrocyanosis, and livedo reticularis. Macroglobulins with the properties of both cryoglobulins and cold agglutinins with anti-Pr specificity can occur. These properties may have as a common basis the binding of the sialic acid–containing carbohydrate present on red blood cell glycophorins and on Ig molecules. Several other macroglobulins with antibody activity toward autologous antigens (e.g., phospholipids, tissue and plasma proteins), and foreign ligands have also been described. IgM Tissue Deposition.  The monoclonal IgM can deposit in several tissues as amorphous aggregates. Linear deposition of monoclonal IgM along the skin basement membrane is associated with bullous skin disease.93 Amorphous IgM deposits in the dermis result in IgM storage papules on the extensor surface of the extremities, referred to as macroglobulinemia cutis.94 Deposition of monoclonal IgM in the lamina propria and/or submucosa of the intestine may be associated with diarrhea, malabsorption, and gastrointestinal bleeding.95,96 Kidney involvement is less common and less severe in WM than in myeloma, probably because the amount of light chain that is excreted in the urine is generally less in WM than in myeloma and because of the absence of contributing factors, such as hypercalcemia.

Urinary cast nephropathy, however, has occurred in WM.97 On the other hand, the IgM macromolecule is more susceptible to being trapped in the glomerular loops, where ultrafiltration presumably contributes to its precipitation, forming subendothelial deposits of aggregated IgM proteins that occlude the glomerular capillaries.98 Mild and reversible proteinuria may result, and most patients are asymptomatic. The deposition of monoclonal light chain as fibrillar amyloid deposits (AL amyloidosis) is uncommon in patients with WM.99 The clinical manifestations and prognosis are similar to those of other patients with AL amyloidosis, with involvement occurring in the heart (44%), kidneys (32%), liver (14%), lungs (10%), peripheral or autonomic nerves (38%), and soft tissues (18%). The incidence of cardiac and pulmonary involvement is higher in patients with monoclonal IgM than in those with other immunoglobulin isotypes. The association of WM with reactive amyloidosis has been documented rarely.100,101 Simultaneous occurrence of fibrillary glomerulopathy, characterized by glomerular deposits of wide noncongophilic fibrils and amyloid deposits, has been described.102

Manifestations Related to Tissue Infiltration by Neoplastic Cells

Tissue infiltration by neoplastic cells is uncommon but can involve various organs and tissues, including the liver, spleen, lymph nodes, lungs, gastrointestinal tract, kidneys, skin, eyes, and central nervous system. Lung.  Pulmonary involvement in the form of masses, nodules, diffuse infiltrate, or pleural effusions is uncommon; the overall incidence of pulmonary and pleural findings is approximately 4%.103–105 Cough is the most common presenting symptom, followed by dyspnea and chest pain. Chest radiographic findings include parenchymal infiltrates, confluent masses, and effusions. Gastrointestinal Tract.  Malabsorption, diarrhea, bleeding, or obstruction may indicate involvement of the gastrointestinal tract at the level of the stomach, duodenum, or small intestine.106–109 Renal System.  In contrast to myeloma, infiltration of the kidney interstitium with lymphoplasmacytoid cell can occur in WM, and renal or perirenal masses are not uncommon.110,111 Skin.  The skin can be the site of dense lymphoplasmacytic infiltrates, similar to those seen in the liver, spleen, and lymph nodes, forming cutaneous plaques and, rarely, nodules.112 Chronic urticaria and IgM

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma

gammopathy are the two cardinal features of the Schnitzler syndrome, which is not usually associated initially with clinical features of WM, although evolution to WM is not uncommon.113 Thus close follow-up of such patients is important. Joints.  Invasion of articular and periarticular structures by WM malignant cells is rarely reported.114 Eye.  The neoplastic cells can infiltrate the periorbital structures, lacrimal gland, and retroorbital lymphoid tissues, resulting in ocular nerve palsies.115,116 Central Nervous System.  Direct infiltration of the central nervous system by monoclonal lymphoplasmacytic cells as infiltrates or as tumors constitutes the rarely observed Bing-Neel syndrome, characterized clinically by confusion, memory loss, disorientation, and motor dysfunction (reviewed by Civit et al.117).

LABORATORY FINDINGS Blood Abnormalities Anemia is the most common finding in patients with symptomatic WM and is caused by a combination of factors: decrease in red cell survival, impaired erythropoiesis, moderate plasma volume expansion, hepcidin production leading to an iron reuse defect, and blood loss from the gastrointestinal tract.16,118,119 Blood films are usually normocytic and normochromic, and rouleau formation is often pronounced. Mean red cell volume may be elevated spuriously owing to erythrocyte aggregation. In addition, the hemoglobin estimate can be inaccurate (i.e., falsely high) because of interaction between the monoclonal protein and the diluent used in some automated analyzers.120 Leukocyte and platelet counts are usually within their reference ranges at presentation, although patients may occasionally present with severe thrombocytopenia. Monoclonal B lymphocytes expressing surface IgM and late-differentiation B-cell markers are uncommonly detected in blood by flow cytometry. A raised erythrocyte sedimentation rate is almost always present and may be the first clue to the presence of macroglobulinemia. The clotting abnormality detected most frequently is prolongation of thrombin time. AL amyloidosis should be suspected in all patients with nephrotic syndrome, cardiomyopathy, hepatomegaly, or peripheral neuropathy. Diagnosis requires the demonstration of green birefringence under polarized light of amyloid deposits stained with Congo red.

MARROW FINDINGS Central to the diagnosis of WM is the demonstration, by trephine biopsy, of marrow infiltration by a lymphoplasmacytic cell population characterized by small lymphocytes with evidence of plasmacytoid and plasma cell maturation (Fig. 87.1).1,14 The pattern of marrow infiltration may be diffuse, interstitial, or nodular, usually with an intertrabecular pattern of infiltration. A solely paratrabecular pattern of infiltration is unusual and should raise the possibility of follicular lymphoma.1 The marrow cell immunophenotype should be confirmed by flow cytometry and/or immunohistochemistry. The cell immunoprofile sIgM+CD19+CD20+CD22+CD79+ is characteristic of WM.14,120,121 Up to 20% of cases may express either CD5, CD10, or CD23.19 In these cases, chronic lymphocytic leukemia and mantle cell lymphoma should be excluded. “Intranuclear” periodic acid-Schiff–positive inclusions (Dutcher-Fahey bodies)122 consisting of IgM deposits in the perinuclear space, and sometimes in intranuclear vacuoles, may be seen occasionally in lymphoid cells. An increased number of mast cells, usually in association with the lymphoid aggregates, is commonly found, and their presence may help in differentiating WM from other B-cell lymphomas (see Fig. 87.3).14 MYD88L265P testing of BM samples has been incorporated

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into many clinical laboratories and may help in clarifying the diagnosis of WM from other IgM-secreting entities.35–39 The use of peripheral blood B cells may also permit determination of MYD88L265P status by allele-specific PCR assays, particularly in untreated patients with WM.

IMMUNOLOGIC ABNORMALITIES High-resolution electrophoresis combined with immunofixation of serum and urine is recommended for identification and characterization of the IgM monoclonal protein. The light chain of the monoclonal IgM is κ in 75% to 80% of patients. More than one M component may be present. The concentration of the serum monoclonal protein is very variable, but in most cases it lies within the range of 15–45 g/L. Densitometry should be adopted to determine IgM levels for serial evaluations because nephelometry is unreliable and shows large laboratory variation. The presence of cold agglutinins or cryoglobulins may affect determination of IgM levels, and therefore testing for cold agglutinins and cryoglobulins should be performed at diagnosis. If present, subsequent serum samples should be analyzed at 37°C for determination of serum monoclonal IgM level. Although Bence Jones proteinuria is frequently present, it exceeds 1 g/24 h in only 3% of cases. Whereas IgM levels are elevated in patients with WM, IgA and IgG levels are most often depressed and do not recover after successful treatment.123

SERUM VISCOSITY Because of their large size (molecular weight almost 1 million), most IgM molecules are retained within the intravascular compartment and can exert an undue effect on serum viscosity.64 Serum viscosity can be measured if the patient has signs or symptoms of hyperviscosity syndrome, though levels are often slow to be reported and erratic owing to a lack of standardization in most clinical laboratories.16 As such, serum IgM levels may be more expedient and relied upon. Patients typically become symptomatic at serum viscosity levels of 4.0 cp and above, which relate to serum IgM levels above 6000 mg/ dL.124,125 Patients may be symptomatic at lower serum viscosity and IgM levels, and in these patients cryoglobulins may be present. Recurring nosebleeds, headaches, and visual disturbances are common symptoms in patients with symptomatic hyperviscosity.16 Funduscopy is an important indicator of clinically relevant hyperviscosity. Among the first clinical signs of hyperviscosity are the appearance of peripheral and midperipheral dot- and blotlike hemorrhages in the retina, which are best appreciated with indirect ophthalmoscopy and scleral depression.68 In more severe cases of hyperviscosity, dot, blot, and flame-shaped hemorrhages can appear in the macular area along with markedly dilated and tortuous veins with focal constrictions resulting in “venous sausaging,” as well as papilledema (Fig. 87.4).

IMAGING Magnetic resonance imaging (MRI) of the spine in conjunction with computed tomography (CT) of the abdomen and pelvis are useful in evaluating disease status.126 Marrow involvement can be documented by MRI studies of the spine in more than 90% of patients; CT of the abdomen and pelvis demonstrates enlarged nodes in approximately 20% of patients with WM at diagnosis, but this proportion may be higher at relapse.126

LYMPH NODE BIOPSY Lymph node biopsy may show preserved architecture or replacement by infiltration of neoplastic cells with lymphoplasmacytoid, lymphoplasmacytic, or polymorphous cytologic patterns.

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Part VII  Hematologic Malignancies

TREATMENT Initiating Treatment As part of the Second International Workshop on Waldenström’s Macroglobulinemia, a consensus panel was organized to recommend criteria for the initiation of therapy in patients with WM.127 The panel recommended that initiation of therapy should not be based on the IgM level per se, because this may not correlate with the clinical manifestations of WM. The consensus panel did, however, agree that initiation of therapy is appropriate for patients with constitutional symptoms, such as recurrent fever, night sweats, fatigue as a consequence of anemia, or weight loss. Progressive symptomatic lymphadenopathy and/or splenomegaly provide additional reasons to begin therapy. Anemia with a hemoglobin value ≤10 g/dL or a platelet count ≤100 × 109/L owing to marrow infiltration also justifies treatment. Certain complications, such as hyperviscosity syndrome, symptomatic sensorimotor peripheral neuropathy, systemic amyloidosis, renal insufficiency, or symptomatic cryoglobulinemia, may also be indications for therapy.16,127

Initial Therapy The International Workshops on Waldenström’s Macroglobulinemia have also formulated consensus recommendations for both initial therapy and therapy for refractory disease based on the best available evidence. The most recent recommendations emerged from the Seventh International Workshop on Waldenström’s Macroglobulinemia.128 Individual patient considerations, including the presence of cytopenias, need for more rapid disease control, age, and candidacy for autologous transplant therapy, should be taken into account in making the choice of the drugs to use. For patients who are candidates for autologous stem cell transplant (SCT), which typically is reserved for those patients younger than 70 years of age, the panel recommended that exposure to alkylating agents or nucleoside analogues should be limited. The use of nucleoside analogues should be approached cautiously in patients with WM because there appears to be an increased risk for the development of disease transformation as well as myelodysplasia and acute myelogenous leukemia. Oral Alkylating Agents.  Oral alkylating drugs, alone and in combination therapy with glucocorticoids, have been evaluated extensively in the treatment of WM. Chlorambucil has been administered on both a continuous (i.e., daily dose schedule) and an intermittent schedule. Patients receiving chlorambucil on a continuous schedule typically receive 0.1 mg/kg per day, whereas on the intermittent schedule patients typically receive 0.3 mg/kg for 7 days, every 6 weeks. In a prospective, randomized study, no significant difference in the overall response rate (ORR) between these schedules was observed,129 although the median response duration was greater for patients receiving intermittent- versus continuous-dose chlorambucil (46 vs. 26 months). Despite the favorable median response duration in this study for use of the intermittent schedule, no difference in the median overall survival was observed. Moreover, an increased incidence for development of myelodysplasia and acute myelogenous leukemia with the intermittent (3 of 22 patients) versus the continuous (0 of 24 patients) chlorambucil schedule prompted the preference for use of continuous chlorambucil dosing. The use of glucocorticoids in combination with alkylating agent therapy has also been explored. Chlorambucil (8 mg/m2) plus prednisone (40 mg/m2) given orally for 10 days, every 6 weeks, resulted in a major response (i.e., reduction of IgM by more than 50%) in 72% of patients.130 Alkylating agent regimens employing melphalan and cyclophosphamide in combination with glucocorticoids have also been examined.131,132 This approach produced slightly higher ORRs and response durations, although the benefit of these more complex regimens over chlorambucil remains to be demonstrated. Pretreatment factors associated with shorter survival in the entire population of patients receiving single-agent chlorambucil were older than 60 years of age,

male sex, hemoglobin less than 10 g/dL, leukocytes less than 4 × 109/L, and platelets less than 150 × 109/L. Organomegaly, signs of hyperviscosity, renal failure, monoclonal IgM level, blood lymphocytosis, and percentage of marrow lymphoid cells were not significantly correlated with survival.133 Additional factors to be taken into account in considering alkylating agent therapy for patients with WM include necessity for more rapid disease control, given the slow response, as well as consideration for preserving stem cells in patients who are candidates for autologous SCT. A large randomized study showed an inferior response rate and time to progression in patients with WM receiving chlorambucil versus fludarabine, as well as a higher incidence of secondary malignancies in the former. Neutropenia was more pronounced, however, in those patients on fludarabine.134 Nucleoside Analogue Therapy.  Cladribine administered as a single agent by continuous intravenous infusion, by 2-hour daily infusion, or by subcutaneous bolus injections for 5–7 days has resulted in major responses in 40% to 90% of patients who received primary therapy, whereas in the previously treated patients, responses have ranged from 38% to 54%.135–141 Median time to achievement of response in responding patients following cladribine ranged from 1.2 to 5 months. The ORR with daily infusion of fludarabine, administered mainly on 5-day schedules, in previously untreated and treated patients ranged from 38% to 100% and from 30% to 40%, respectively,142–147 similar to the responses to cladribine. Median time to achievement of response for fludarabine (3–6 months) was also similar to cladribine. In general, response rates and durations of responses have been greater for patients receiving nucleoside analogues as initial therapy, although no difference in the ORR was reported in several studies in which both untreated and previously treated patients were enrolled. Myelosuppression commonly occurs following prolonged exposure to either of the nucleoside analogues. A sustained decrease in both CD4+ and CD8+ T lymphocytes, measured 1 year following initiation of therapy, is notable.135–137 Treatment-related mortality as a consequence of myelosuppression and/or opportunistic infections attributable to immunosuppression occurred in up to 5% of all treated patients in some series with nucleoside analogues. Factors predicting a better response to nucleoside analogues include younger age at start of treatment (<70 years), higher pretreatment hemoglobin (>95 g/L), higher platelet count (>75 × 109/L), disease relapsing off-therapy, and a long interval between firstline therapy and initiation of a nucleoside analogue in relapsing patients.135,140,146 There are limited data on the use of an alternate nucleoside analogue in previously treated patients in whom disease relapsed or who had resistance when not on cladribine or fludarabine therapy.148,149 Three (75%) of 4 patients responded to cladribine after progression following an unmaintained remission with fludarabine, whereas only 1 (10%) of 10 with disease resistant to fludarabine responded to cladribine.148 A response to fludarabine has been reported in two (33%) of six patients and disease stabilization in the remaining patients, in spite of an inadequate response or progressive disease, following cladribine therapy.149 Harvesting autologous blood stem cells succeeded on the first attempt in 14 of 15 patients who did not receive nucleoside analogue therapy, as compared with 2 of 6 patients who received a nucleoside analogue.150 A sevenfold increase in patients transforming to an aggressive lymphoma and a threefold increase in the development of myelodysplasia or acute myelogenous leukemia were observed among patients who received a nucleoside analogue versus other therapies for their WM.151 A meta-analysis of several trials in which patients with WM were treated with nucleoside analogues included patients who had previously received an alkylating agent, and the results showed a crude incidence of approximately 8% of developing a disease transformation event and approximately 5% for developing myelodysplasia or acute myelogenous leukemia.152 None of the risk factors—that is, sex, age, family history of WM, or B-cell malignancies, typical markers of tumor burden and prognosis, type of nucleoside analogue therapy (cladribine vs. fludarabine), time from diagnosis to nucleoside analogue use, nucleoside analogue treatment as primary

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma

or salvage therapy, or treatment with an oral alkylator (i.e., chlorambucil)—predicted the occurrence of transformation or development of myelodysplasia or acute myelogenous leukemia in patients treated with a nucleoside analogue.152 CD20-Directed Antibody Therapy.  Rituximab is a chimeric monoclonal antibody that targets CD20, a widely expressed antigen on lymphoplasmacytic cells in WM.153 Several retrospective and prospective studies have indicated that rituximab, when used at standard doses (i.e., 4 weekly infusions of 375 mg/m2/week) induced major responses in approximately 30% of previously treated and untreated patients.154,155 Even patients who achieved minor responses benefited from rituximab by improved hemoglobin and platelet counts, as well as reduction of lymphadenopathy and/or splenomegaly.154 The median time to treatment failure in these studies was found to range from 8 to 27+ months. Patients on an extended rituximab schedule consisting of 4 weekly courses at 375 mg/m2 per week, repeated 3 months later by another 4-week course have demonstrated major response rates of approximately 45%, with time to progression estimates of 16+ to 29+ months.156,157 In many patients with WM, a transient increase or flare of the serum IgM may occur immediately following initiation of rituximab treatment.156,158,159 Such an increase does not herald treatment failure, and most patients will return to their baseline serum IgM level by 12 weeks. Some patients continue to show a prolonged increase in IgM despite an apparent reduction in their marrow tumor cells. However, patients with baseline serum IgM levels >50 g/dL or serum viscosity >3.5 cp may be particularly at risk for a hyperviscosity-related event, and plasmapheresis should be considered in these patients in advance of rituximab therapy.158 Because of the decreased likelihood of response in patients with higher IgM levels, as well as the possibility that serum IgM and blood viscosity levels may abruptly rise, rituximab monotherapy should not be used as sole therapy for the treatment of patients at risk for hyperviscosity symptoms.128,156,157 Time to response after rituximab is slow and exceeds 3 months on average. The time to best response in one study was 18 months.157 Patients with baseline serum IgM levels <60 g/dL are more likely to respond, regardless of the underlying degree of marrow involvement by tumor cells.156,157 An analysis of 52 patients who were treated with single-agent rituximab found the objective response rate was significantly lower in patients who had either low serum albumin (<35 g/L) or a serum monoclonal protein greater than 40 g/L.160 The presence of both adverse prognostic factors was associated with a short time to progression (3.6 months). Patients who had normal serum albumin and relatively low serum monoclonal protein levels derived a substantial benefit from rituximab, with a time to progression exceeding 40 months. A correlation between polymorphisms at position 158 in the FcγRIIIa receptor (CD16), an activating Fc receptor on important effector cells that mediate antibody-dependent, cell-mediated cytotoxicity, and rituximab response was observed in patients with WM.161 Individuals may encode either the amino acid valine or phenylalanine at position 158 in the FcγRIIIa receptor. Patients with WM who carried the valine amino acid (either in a homozygous or heterozygous pattern) had a fourfold higher major response rate (i.e., 50% decline in serum IgM levels) to rituximab versus those patients who expressed phenylalanine in a homozygous pattern. Proteasome Inhibitors.  Both bortezomib and carfilzomib have been evaluated in prospective studies in patients with WM, though the latter only in combination therapy (discussed below). In a retrospective study, 10 patients with refractory or relapsed WM were treated with bortezomib administered intravenously at a dose of 1.3 mg/m2 on days 1, 4, 8, and 11 in a 21-day cycle for a total of four cycles. Most patients had been exposed to all other active agents for WM, and eight patients had received three or more regimens. Six of these patients achieved a partial response that occurred after a median of 1 month. The median time to progression in the responding patients is expected to exceed 11 months. Peripheral neuropathy occurred in three patients, and one patient developed severe paralytic ileus.162 In

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a prospective study including 27 relapsed or refractory patients who received up to 8 cycles of bortezomib at 1.3 mg/m2 on days 1, 4, 8, and 11, median serum IgM levels declined significantly, from 4.7 g/ dL to 2.1 g/dL.33 The ORR was 85%, with 10 and 13 patients achieving a minor (<25%) and major (<50%) decrease in IgM level, respectively. Responses occurred after a median of 1.4 months. The median time to progression for all responding patients in this study was 7.9 (range, 3–21.4+) months, and the most common grade III/ IV toxicities were sensory neuropathies (22.2%), leukopenia (18.5%), neutropenia (14.8%), dizziness (11.1%), and thrombocytopenia (7.4%). Sensory neuropathies resolved or improved in nearly all patients following cessation of therapy. Twenty-seven patients with both untreated (44%) and previously treated (56%) disease received bortezomib, using the standard schedule until they either demonstrated progressive disease or two cycles beyond a complete response or stable disease.163 The ORR was 78%, with major responses observed in 44% of patients. Sensory neuropathy occurred in 20 patients following two to four cycles of therapy. Among the 20 patients who developed a neuropathy, 14 showed resolution or improvement 2–13 months after therapy. Combination Therapies.  Because rituximab is not myelosuppressive, its use in combination with chemotherapy has been explored. A regimen of rituximab, cladribine, and cyclophosphamide in 17 previously untreated patients resulted in a partial response in 94% of patients with WM, including a complete response in 18%.164 No patient had relapsed with a median follow-up of 21 months. The combination of rituximab and fludarabine was used in 43 patients, of whom 32 (75%) were previously untreated, which led to an ORR of 95.3%, with 83% of patients achieving a major response (i.e., 50% reduction in disease burden).165 The median time to progression was 51.2 months in this series, and it was longer for those patients who were previously untreated and for those achieving a very good partial remission (i.e., 90% reduction in disease) or better. Hematologic toxicity was common: Grade 3 neutropenia and thrombocytopenia were observed in 27 and 4 patients, respectively. Two deaths occurred in this study as a result of pneumonia. Secondary malignancies, including transformation to aggressive lymphoma and development of myelodysplasia or acute myelogenous leukemia, were observed in six patients. The addition of rituximab to fludarabine and cyclophosphamide has also been explored in previously treated patients, and four of five patients had a response.166 In another combination study, rituximab along with pentostatin and cyclophosphamide given to 13 patients with untreated and previously treated WM or LPL resulted in a major response in 77% of patients.167 The combination of rituximab, dexamethasone, and cyclophosphamide was used as primary therapy to treat 72 patients with WM, among whom a major response was observed in 74% of patients, and the 2-year progressionfree survival was 67%.168 Therapy was well tolerated, although one patient died as a result of interstitial pneumonia. Two studies have examined cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy in combination with rituximab (R-CHOP). In a randomized trial involving 69 patients, most of whom had WM, the addition of rituximab to CHOP resulted in a higher ORR (94% vs. 67%) and median time to progression (63 vs. 22 months) in comparison to patients treated with CHOP alone.169 R-CHOP was also used in 13 patients with WM, 10 of whom had relapsed or refractory disease.170 Among 13 evaluable patients, 10 patients achieved a major response (77%), including 3 complete and 7 partial remissions. Two other patients achieved a minor response. Patients in a retrospective study of symptomatic WM received either R-CHOP; rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP); or cyclophosphamide, prednisone, and rituximab (R-CP). The patients were similar in most pretreatment variables, and the ORRs to therapy were comparable among all three treatment groups—R-CHOP (96%), R-CVP (88%), and R-CP (95%)—although there was a trend for more complete remissions among patients treated with R-CVP and R-CHOP.171 Adverse events attributed to therapy showed a higher incidence for neutropenic fever and treatment-related neuropathy for R-CHOP and R-CVP versus

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Part VII  Hematologic Malignancies

R-CP. The results of this study suggest that in patients with WM, the use of R-CP may provide treatment responses analogous to those of more intense cyclophosphamide-based regimens while minimizing treatment-related complications. The extended alkylator bendamustine has also been evaluated in combination with rituximab in both untreated and previously treated patients with WM. A randomized study by the German STiL Group examined bendamustine plus rituximab (Benda-R) versus R-CHOP in patients with untreated, indolent B-cell lymphomas including WM.172 Patients with WM in this study showed similar overall responses (96% vs. 94%), though progression-free survival was significantly longer (69 vs. 29 months) in patients who received Benda-R versus R-CHOP. Treatment was also better tolerated in patients receiving Benda-R. In the relapsed or refractory setting, an ORR of 83% was observed with bendamustine in combination with a CD20 monoclonal antibody.173 The median time to progression was 13 months in this study. Prolonged myelosuppression was more common in patients who had received prior nucleoside analogue therapy. The use of two cycles of oral cyclophosphamide along with subcutaneous cladribine to 37 patients with previously untreated WM led to a partial response in 84% of patients, and the median duration of response was 36 months.164 Fludarabine in combination with intravenous cyclophosphamide resulted in partial responses in 6 (55%) of 11 patients with WM with either primary refractory disease or who had relapsed on treatment.174 The combination of fludarabine plus cyclophosphamide was also evaluated in 49 patients, 35 of whom were previously treated. Seventy-eight percent of the patients achieved a response, and the median time to treatment failure was 27 months.175 Hematologic toxicity was frequent, and three patients died as a result of treatment-related toxicities. Two important findings in this study were the development of acute leukemia in two patients, histologic transformation to diffuse large B-cell lymphoma in one patient, and two cases of solid malignancies (prostate and melanoma), as well as failure to mobilize stem cells in four of six patients. The combination of bortezomib, dexamethasone, and rituximab (BDR) as primary therapy in patients with WM resulted in an ORR of 96% and a major response rate of 83%.176 The incidence of grade 3 neuropathy was approximately 30%, but this was reversible in most patients following discontinuation of therapy. An increased incidence of herpes zoster was also observed, prompting the prophylactic use of antiviral therapy. Alternative schedules for administration of bortezomib (i.e., once weekly at higher doses) in combination with rituximab in patients with WM have achieved ORRs of 80% to 90%.177,178 The European Myeloma Network recently showed that transitioning bortezomib from twice-weekly intravenous dosing during the first cycle to weekly administration thereafter reduced grade 3 neuropathy to under 10% in patients treated with BDR.179 There have been no studies addressing the safety and efficacy of subcutaneous bortezomib use in WM. Carfilzomib, which is associated with a low risk of treatmentrelated peripheral neuropathy, has been evaluated in combination with rituximab and dexamethasone in patients with WM.34 Carfilzomib was administered intravenously at 20 mg/m2 (cycle 1), then 36 mg/ m2 (cycles 2–6), together with dexamethasone (20 mg) on days 1, 2, 8, and 9 as part of a 21-day cycle. As part of this regimen, rituximab 375 mg/m2 was given on days 2 and 9 every 21 days. Maintenance therapy was given 8 weeks following induction therapy with intravenous carfilzomib (36 mg/m2) and dexamethasone (20 mg) administered on days 1 and 2 and with rituximab 375 mg/m2 on day 2 every 8 weeks for up to 8 cycles. The ORR with this regimen was 87.1% (1 complete response, 10 very good partial responses, 10 partial responses, and 6 minimal responses) and was not impacted by MYD88L265P or CXCR4WHIM mutation status. With a median follow-up of 15.4 months, 20 patients remained progression-free. Grade ≥2 toxicities included asymptomatic hyperlipasemia (41.9%), reversible neutropenia (12.9%), and cardiomyopathy in 1 patient (3.2%) with multiple risk factors. Grade 2treatment-related neuropathy occurred in one patient (3.2%). Declines in serum IgA and IgG were common, and some patients required intravenous immunoglobulin therapy for recurring sinus and bronchial infections.

Novel Therapeutics.  The use of ibrutinib was recently approved by the U.S. Food and Drug Administration for the treatment of symptomatic patients with WM. Ibrutinib targets BTK, a target of ibrutinib that is activated by MYD88L265P.43 In a multicenter study in which researchers examined the role of ibrutinib in previously treated (median 2 prior therapies, 40% refractory) patients with WM, the ORR was 87%.180 Patients on this study received 420 mg per day of ibrutinib by mouth. Posttherapy median serum IgM levels declined from 3610 to 915 mg/dL; hemoglobin rose from 10.5 to 13.5 g/dL; and BM involvement declined from 60% to 30%. Decreased or resolved adenopathy was observed in 60% of patients with extramedullary disease, and five of nine patients with IgM-related peripheral neuropathy had symptomatic improvement. The 18-month estimates for progression-free and overall survival were 83% and 93%, respectively. Although major response rates were lower in patients with MYD88wild-type and CXCR4WHIM mutations, it is not recommended that genotyping be used to select which patients should be placed on ibrutinib until further data are available. Grade ≥2 treatment-related toxicities included neutropenia (25%) and thrombocytopenia (14%) that were more common in heavily pretreated patients, atrial fibrillation associated with a prior history of arrhythmia (5%), and bleeding associated with procedures and marine oil supplements (3%). Serum IgA and IgG levels were unchanged following treatment with ibrutinib, and treatment-related infections were infrequent. Everolimus is an oral inhibitor of the mammalian target of rapamycin (mTOR) pathway that is active in WM. In a multicenter study, investigators examined everolimus in 60 previously treated patients and showed an ORR of 73%, with 50% of patients attaining a major response.181 The median progression-free survival in this study was 21 months. Grade 3 or higher related toxicities were observed in 67% of patients, with cytopenias constituting the most common toxicity. Pulmonary toxicity occurred in 5% of patients, and dose reductions owing to toxicity occurred in 52% of patients. In a clinical trial in which researchers examined the activity of everolimus in 33 previously untreated patients with WM, serial BM biopsies were included in response assessment.182 The ORR in this study was 72%, including partial or better responses in 60% of patients. However, discordance between serum IgM levels upon which consensus criteria for response are based and BM disease response was common, which complicated response assessment. In a few patients, discontinuation of everolimus led to rapid increases in serum IgM levels and symptomatic hyperviscosity. Grade ≥2 hematologic and nonhematologic toxicities in this study that were related to everolimus were predominately hematological, including anemia (40%), thrombocytopenia (12%), and neutropenia (18%). Nonhematologic toxicities included oral ulcerations (27%) that improved with oral dexamethasone swish and spit solution, as well as pneumonitis (15%), the latter leading to treatment discontinuation. Maintenance Therapy.  The outcome of rituximab-naïve patients who were either observed or received maintenance rituximab categorical responses was examined in a large retrospective study.183 Categorical responses improved after induction therapy in 42% of patients who received maintenance rituximab versus 10% in patients in the observation group. Additionally, both progression-free (56.3 vs. 28.6 months) and overall (>120 vs. 116 months) survival were longer in patients who received maintenance rituximab. Improved progressionfree survival was evident despite previous treatment status, induction with rituximab alone, or in combination therapy. Best serum IgM response was also lower, and hematocrit higher, in those patients who received maintenance rituximab. Among patients who received maintenance rituximab therapy, an increased number of infectious events, predominantly grade 1 or 2 sinusitis and bronchitis, was observed, along with lower serum IgA and IgG levels. A prospective study examining the role of maintenance rituximab has also been initiated by the German STiL Group.184 In this study, patients received up to six cycles of bendamustine and rituximab, and responders were randomized to either observation or maintenance rituximab every 2 months for 2 years. Enrollment for this study is complete, and response outcome for maintenance rituximab therapy is awaited.

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma

High-Dose Therapy and Stem Cell Transplant

The European Bone Marrow Transplant Registry (EBMT) reported the largest experience for both autologous as well as allogeneic SCT in WM.185,186 Among 158 patients with WM receiving an autologous SCT, which included primarily relapsed or refractory patients, the 5-year progression-free and overall survival rates were 39.7% and 68.5%, respectively.185 Nonrelapse mortality at 1 year was 3.8%. Chemorefractory disease and the number of prior lines of therapy at the time of the autologous SCT were the most important prognostic factors for progression-free and overall survival. In the allogeneic SCT experience from the EBMT, the long-term outcomes of 86 patients with WM were reported.186 A total of 86 patients received an allograft following either myeloablative or reduced-intensity conditioning. The median age of patients in this series was 49 years, and 47 patients had undergone three or more previous lines of therapy. Eight patients failed prior autologous SCT. Fifty-nine patients (68.6%) had chemotherapy-sensitive disease at the time of allogeneic SCT. Nonrelapse mortality rates at 3 years were 33% for patients receiving a myeloablative transplant and 23% for those who received reducedintensity conditioning. The ORR was 75.6%. The relapse rates at 3 years were 11% for myeloablative and 25% for reduced-intensity conditioning recipients. Five-year progression-free and overall survival for patients with WM who received a myeloablative allogeneic SCT were 56% and 62%, respectively, and for patients who received reduced intensity conditioning, the rates were 49% and 64%, respectively. The occurrence of chronic graft-versus-host disease was associated with improved progression-free survival and suggested the existence of a clinically relevant graft-versus-WM effect in this study.

Response Criteria in Waldenström Macroglobulinemia Table 87.3 summarizes the response categories and criteria for progressive disease in WM based on the most recent consensus recommendations.187 The term overall response is used to characterize all responses, including minor responses. Major responses include partial, very good partial, and complete responses. The attainment of very good partial or complete responses is associated with improved

TABLE 87.3

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progression-free survival.155,165,176,179,188 Response assessments in WM rely primarily on serum IgM or IgM paraprotein levels, though complete responses require disappearance of the IgM monoclonal protein, and resolution of evidence of BM and/or extramedullary disease.187 An important concern with the use of IgM as a surrogate marker of disease is that it can fluctuate independent of tumor cell killing with some agents. By way of example, rituximab can induce a flare in serum IgM levels, whereas everolimus, bortezomib, and ibrutinib can suppress IgM levels independent of tumor cell killing in some patients, a phenomenon referred to as IgM discordance.158,159,162,181,183,189 Moreover, with selective B cell–depleting agents such as rituximab and alemtuzumab, residual IgM-producing plasma cells are spared and persist, thus potentially skewing the relative response and assessment to treatment.190 Soluble CD27 levels have been investigated as an alternative surrogate marker in WM, given their correlation with WM disease burden, and may remain a faithful marker of disease in patients experiencing a rituximab-related IgM flare, as well as after plasmapheresis.60,191 The use of quantitative allele-specific PCR assays to assess serial MYD88L265P burden in patients with WM is also under investigation.36,38

Course and Prognosis WM typically presents as an indolent disease. The presence of 6q deletions may have prognostic significance, although this is disputed.20,21 Age is an important prognostic factor (>65 years),192–194 but it is influenced by comorbidities. Anemia that reflects both marrow involvement and the serum level of the IgM monoclonal protein (because of the impact of IgM on intravascular fluid retention) has emerged as a strong adverse prognostic factor with hemoglobin levels of <9 to 12 g/dL associated with decreased survival in several series.192–194 Other cytopenias also may be significant predictors of survival.193 The precise level of cytopenias with prognostic significance has not been determined. Some series have identified a platelet count of <100 to 150 × 109/L and a granulocyte count of <1.5 × 109/L as independent prognostic factors.193,194 The number of cytopenias in a given patient has been proposed as a prognostic factor.193 Serum albumin levels also correlate with survival in patients

Summary of Consensus Response Criteria for Waldenström Macroglobulinemia187

Response Type

Abbreviation

Criteria

Complete response

CR

Absence of serum monoclonal IgM protein by immunofixation Normal serum IgM level Complete resolution of extramedullary disease (i.e., lymphadenopathy/splenomegaly if present at baseline) Morphologically normal bone marrow aspirate and trephine biopsy

Very good partial response

VGPR

Monoclonal IgM protein is detectable 90% reduction in serum IgM level from baseline or normalization of serum IgM level Complete resolution of extramedullary disease (i.e., lymphadenopathy/splenomegaly if present at baseline) No new signs or symptoms of active disease

Partial response

PR

Monoclonal IgM protein is detectable ≥50% but <90% reduction in serum IgM level from baseline Reduction in extramedullary disease (i.e., lymphadenopathy/splenomegaly if present at baseline) No new signs or symptoms of active disease

Minor response

MR

Monoclonal IgM protein is detectable ≥25% but <50% reduction in serum IgM level from baseline No new signs or symptoms of active disease

Stable disease

SD

Monoclonal IgM protein is detectable <25% reduction and <25% increase in serum IgM level from baseline No progression in extramedullary disease (i.e., lymphadenopathy/splenomegaly) No new signs or symptoms of active disease

Progressive disease

PD

>25% increase in serum IgM level from lowest nadir (requires confirmation) and/or progression in clinical features attributable to the disease

IgM, Immunoglobulin M.

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Part VII  Hematologic Malignancies

TABLE 87.4

Prognostic Scoring Systems in Waldenström Macroglobulinemia

Study

Adverse Prognostic Factors

Number of Groups

Survival

Gobbi et al.

Hgb <9 g/dL Age >70 years Weight loss Cryoglobulinemia

0–1 prognostic factors 2–4 prognostic factors

Median: 48 months Median: 80 months

Morel et al.193

Age ≥65 years Albumin <4 g/dL Number of cytopenias:   Hgb <12 g/dL   Platelets <150 × 109/L   WBC <4 × 109/L

0–1 prognostic factors 2 prognostic factors 3–4 prognostic factors

5-year: 87% of patients 5-year: 62% 5-year: 25%

Dhodapkar et al.194

β2M ≥3 g/dL Hgb <12 g/dL IgM <4 g/dL

β2M β2M β2M β2M

5-year: 5-year: 5-year: 5-year:

Dimopoulos et al.195

Albumin ≤3.5 g/dL β2M ≥3.5 mg/L

Albumin ≥3.5 g/dL + β2M <3.5 mg/dL Albumin ≤3.5 g/dL + β2M <3.5 or β2M 3.5–5.5 mg/dL β2M >5.5 mg/dL

Median: NR Median: 116 months Median: 54 months

Morel et al.197

Age >65 years Hgb <11.5 g/dL Platelets <100 × 109/L β2M >3 mg/L IgM >7 g/dL

0–1 prognostic factors (excluding age) 2 prognostic factors (or age >65 years) 3–5 prognostic factors

5 year: 87% of patients 5 year: 68% 5 year: 36%

192

<3 mg/dL <3 mg/dL ≥3 mg/dL ≥3 mg/dL

+ + + +

Hgb ≥12 g/dL Hgb <12 g/dL IgM ≥4 g/dL IgM <4 g/dL

87% of patients 63% 53% 21%

β2M, β2-microbloulin; Hgb, hemoglobulin; IgM, immunoglobulin M; NR, not reported; WBC, white blood cell count.

with WM in some studies, using multivariate analyses.193,195 Elevated serum β2-microglobulin levels (>3–3.5 g/dL) have also been shown to have strong prognostic correlation in WM.193–196 Several scoring systems have been proposed that are based on these analyses (Table 87.4), including the International Prognostic Scoring System for Waldenström macroglobulinemia (IPSSWM), which incorporates five adverse covariates: advanced age (>65 years), hemoglobin ≤11.5 g/dL, platelet count ≤100 × 109/L, β2-microglobulin >3 mg/L, and serum monoclonal protein concentration >7.0 g/dL.197 Among 537 patients with WM evaluated in the development of IPSSWM, low-risk patients (27%) presented with no or one of the adverse characteristics and advanced age; intermediate-risk patients (38%) presented with two adverse characteristics or only advanced age; and high-risk patients (35%) presented with more than two adverse characteristics. Five-year survival rates for these three patient groups were 87%, 68%, and 36%, respectively. Importantly, the IPSS WM retained its prognostic significance in subgroups defined by age and treatment with alkylating agent and nucleoside analogues. Recent data from the Surveillance, Epidemiology, and End Results (SEER) database involving 7744 patients with WM showed that the relative survival of patients with WM has improved over time. Patients diagnosed during 2001–2010 had higher 5-year (78% vs. 67%) and 10-year (66% vs. 49%) relative survival rates versus patients diagnosed during 1980–2000. A Greek study that included 345 patients with WM failed to show any overall or cause-specific survival improvement in recent years, though the study might have been underpowered to detect any expected benefit.196 A Swedish study of 1555 patients diagnosed with WM between 1980 and 2005 showed that the 5-year relative survival rate improved from 57% in 1980–1985 to 78% in 2001–2005.198

REFERENCES For the complete list of references, log on to www.expertconsult.com.

SUGGESTED READINGS Ansell SM, Hodge LS, Secreto FJ, et al: Activation of TAK1 by MYD88 L265P drives malignant B-cell growth in non-Hodgkin lymphoma. Blood Cancer J 4:e183, 2014. Braggio E, Keats JJ, Leleu X, et al: Identification of copy number abnormalities and inactivating mutations in two negative regulators of nuclear factor-κB signaling pathways in Waldenström’s macroglobulinemia. Cancer Res 69:3579, 2009. Cao Y, Hunter ZR, Liu X, et al: The WHIM-like CXCR4S338X somatic mutation activates AKT and ERK, and promotes resistance to ibrutinib and other agents used in the treatment of Waldenström’s macroglobulinemia. Leukemia 29:169, 2015. Castillo JJ, Olszewski A, Cronin AM, et al: Survival trends in Waldenström macroglobulinemia: an analysis of the Surveillance, Epidemiology and End Results database. Blood 123:3999, 2014. Castillo JJ, Treon SP, Davids MS: Inhibition of the Bruton tyrosine kinase pathway in B-cell lymphoproliferative disorders. Cancer J 22:34, 2016. Dimopoulos MA, Kastritis E, Owen RG, et al: Treatment recommendations for patients with Waldenström macroglobulinemia (WM) and related disorders: IWWM-7 consensus. Blood 124:1404, 2014. Ho AW, Hatjiharissi E, Ciccarelli BT, et al: CD27-CD70 interactions in the pathogenesis of Waldenström macroglobulinemia. Blood 112:4683, 2008. Hunter ZR, Xu L, Yang G, et al: The genomic landscape of Waldenstom’s macroglobulinemia is characterized by highly recurring MYD88 and WHIM-like CXCR4 mutations, and small somatic deletions associated with B-cell lymphomagenesis. Blood 123:1637, 2014. Jiménez C, Sebastián E, Del Carmen Chillón M, et al: MYD88 L265P is a marker highly characteristic of, but not restricted to, Waldenström’s macroglobulinemia. Leukemia 27:1722, 2013. Kastritis S, Kyrtsonis MC, Hatjiharissi E, et al: No significant improvement in the outcome of patients with Waldenström macroglobulinemia treated over the last 25 years. Am J Hematol 86:479, 2011. Kristinsson SY, Eloranta S, Dickman PW, et al: Patterns of survival in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia: a

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma population based study of 1,555 patients diagnosed in Sweden from 1980 to 2005. Am J Hematol 88:60, 2013. Kyle RA, Treon SP, Alexanian R, et al: Prognostic markers and criteria to initiate therapy in Waldenström’s macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenström’s Macroglobulinemia. Semin Oncol 30:116, 2003. Menke MN, Feke GT, McMeel JW, et al: Hyperviscosity-related retinopathy in Waldenström’s macroglobulinemia. Arch Ophthalmol 124:1601, 2006. Merlini G, Baldini L, Broglia C, et al: Prognostic factors in symptomatic Waldenström’s macroglobulinemia. Semin Oncol 30:211, 2003. Merlini G, Farhangi M, Osserman EF: Monoclonal immunoglobulins with antibody activity in myeloma, macroglobulinemia and related plasma cell dyscrasias. Semin Oncol 13:350, 1986. Morel P, Duhamel A, Gobbi P, et al: International prognostic scoring system for Waldenström macroglobulinemia. Blood 113:4163, 2009. Nobile-Orazio E, Marmiroli P, Baldini L, et al: Peripheral neuropathy in macroglobulinemia: incidence and antigen-specificity of M proteins. Neurology 37:1506, 1987. Nguyen-Khac F, Lambert J, Chapiro E, et al: Chromosomal aberrations and their prognostic value in a series of 174 untreated patients with Waldenström’s macroglobulinemia. Haematologica 98:649, 2013. Owen RG, Treon SP, Al-Katib A, et al: Clinicopathological definition of Waldenström’s macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenström’s Macroglobulinemia. Semin Oncol 30:110, 2003. Poulain S, Roumier C, Decambron A, et al: MYD88 L265P mutation in Waldenström’s macroglobulinemia. Blood 121:4504, 2013. Roccaro A, Sacco A, Jiminez C, et al: C1013G/CXCR4 acts as a driver mutation of tumor progression and modulator of drug resistance in lymphoplasmacytic lymphoma. Blood 123:4120, 2014.

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Stone MJ, Bogen SA: Evidence-based focused review of management of hyperviscosity syndrome. Blood 119:2205, 2012. Swerdlow SH, Campo E, Harris NL, et al: WHO classification of tumours of haematopoietic and lymphoid tissues, ed 4, Lyon, France, 2008, IARC Press. Treon SP, Hunter ZR, Aggarwal A, et al: Characterization of familial Waldenström’s macroglobulinemia. Ann Oncol 17:488, 2006. Treon SP, Xu L, Yang G, et al: MYD88 L265P somatic mutation in Waldenström’s macroglobulinemia. N Engl J Med 367:826, 2012. Treon SP, Cao Y, Xu L, et al: Somatic mutations in MYD88 and CXCR4 are determinants of clinical presentation and overall survival in Waldenström macroglobulinemia. Blood 123:2791, 2014. Treon SP: How I treat Waldenström macroglobulinemia. Blood 126:721, 2015. Treon SP, Tripsas CK, Meid K, et al: Ibrutinib in previously treated Waldenström’s macroglobulinemia. N Engl J Med 372:1430, 2015. Varettoni M, Arcaini L, Zibellini S, et al: Prevalence and clinical significance of the MYD88 L265P somatic mutation in Waldenström macroglobulinemia, and related lymphoid neoplasms. Blood 121:2522, 2013. Xu L, Hunter Z, Yang G, et al: MYD88 L265P in Waldenström macroglobulinemia, immunoglobulin M monoclonal gammopathy, and other B-cell lymphoproliferative disorders using conventional and quantitative allele-specific polymerase chain reaction. Blood 121:2051, 2013. Yang G, Zhou Y, Liu X, et al: A mutation in MYD88 (L265P) supports the survival of lymphoplasmacytic cells by activation of Bruton tyrosine kinase in Waldenström macroglobulinemia. Blood 122:1222, 2013.

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma

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Part VII  Hematologic Malignancies

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Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma 97. Isaac J, Herrera GA: Cast nephropathy in a case of Waldenström’s macroglobulinemia. Nephron 91:512, 2002. 98. Morel-Maroger L, Basch A, Danon F, et al: Pathology of the kidney in Waldenström’s macroglobulinemia: study of sixteen cases. N Engl J Med 283:123, 1970. 99. Gertz MA, Kyle RA, Noel P: Primary systemic amyloidosis: a rare complication of immunoglobulin M monoclonal gammopathies and Waldenström’s macroglobulinemia. J Clin Oncol 11:914, 1993. 100. Moyner K, Sletten K, Husby G, et al: An unusually large (83 amino acid residues) amyloid fibril protein AA from a patient with Waldenström’s macroglobulinaemia and amyloidosis. Scand J Immunol 11:549, 1980. 101. Gardyn J, Schwartz A, Gal R, et al: Waldenström’s macroglobulinemia associated with AA amyloidosis. Int J Hematol 74:76, 2001. 102. Dussol B, Kaplanski G, Daniel L, et al: Simultaneous occurrence of fibrillary glomerulopathy and AL amyloid. Nephrol Dial Transplant 13:2630, 1998. 103. Rausch PG, Herion JC: Pulmonary manifestations of Waldenström macroglobulinemia. Am J Hematol 9:201, 1980. 104. Fadil A, Taylor DE: The lung and Waldenström’s macroglobulinemia. South Med J 91:681, 1998. 105. Kyrtsonis MC, Angelopoulou MK, Kontopidou FN, et al: Primary lung involvement in Waldenström’s macroglobulinaemia: report of two cases and review of the literature. Acta Haematol 105:92, 2001. 106. Kaila VL, el Newihi HM, Dreiling BJ, et al: Waldenström’s macroglobulinemia of the stomach presenting with upper gastrointestinal hemorrhage. Gastrointest Endosc 44:73, 1996. 107. Yasui O, Tukamoto F, Sasaki N, et al: Malignant lymphoma of the transverse colon associated with macroglobulinemia. Am J Gastroenterol 92:2299, 1997. 108. Rosenthal JA, Curran WJ, Jr, Schuster SJ: Waldenström’s macroglobulinemia resulting from localized gastric lymphoplasmacytoid lymphoma. Am J Hematol 58:244, 1998. 109. Recine MA, Perez MT, Cabello-Inchausti B, et al: Extranodal lymphoplasmacytoid lymphoma (immunocytoma) presenting as small intestinal obstruction. Arch Pathol Lab Med 125:677, 2001. 110. Veltman GA, van Veen S, Kluin-Nelemans JC, et al: Renal disease in Waldenström’s macroglobulinaemia. Nephrol Dial Transplant 12:1256, 1997. 111. Moore DF, Jr, Moulopoulos LA, Dimopoulos MA: Waldenström macroglobulinemia presenting as a renal or perirenal mass: clinical and radiographic features. Leuk Lymphoma 17:331, 1995. 112. Mascaro JM, Montserrat E, Estrach T, et al: Specific cutaneous manifestations of Waldenström’s macroglobulinaemia: a report of two cases. Br J Dermatol 106:17, 1982. 113. Schnitzler L, Schubert B, Boasson M, et al: Urticaire chronique, lésions osseuses, macroglobulinémie IgM: maladie de Waldenström? Bull Soc Fr Dermatol Syphiligr 81:363, 1974. 114. Roux S, Fermand JP, Brechignac S, et al: Tumoral joint involvement in multiple myeloma and Waldenström’s macroglobulinemia—report of 4 cases. J Rheumatol 23:2175, 1996. 115. Orellana J, Friedman AH: Ocular manifestations of multiple myeloma, Waldenström’s macroglobulinemia and benign monoclonal gammopathy. Surv Ophthalmol 26:157, 1981. 116. Ettl AR, Birbamer GG, Philipp W: Orbital involvement in Waldenström’s macroglobulinemia: ultrasound, computed tomography and magnetic resonance findings. Ophthalmologica 205:40, 1992. 117. Civit T, Coulbois S, Baylac F, et al: Waldenström’s macroglobulinemia and cerebral lymphoplasmacytic proliferation: Bing and Neel syndrome. Report of a new case [in French]. Neurochirurgie 43:245, 1997. 118. Ciccarelli BT, Patterson CJ, Hunter ZR, et al: Hepcidin is produced by lymphoplasmacytic cells and is associated with anemia in Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma Leuk 11:160, 2011. 119. Treon SP, Tripsas C, Ciccarelli BT, et al: Patients with Waldenström macroglobulinemia commonly present with iron deficiency and those with severely depressed transferrin saturation levels show response to parenteral iron administration. Clin Lymphoma Myeloma Leuk 13:241, 2013. 120. Owen RG, Barrans SL, Richards SJ, et al: Waldenström macroglobulinemia: development of diagnostic criteria and identification of prognostic factors. Am J Clin Pathol 116:420, 2001.

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121. Feiner HD, Rizk CC, Finfer MD, et al: IgM monoclonal gammopathy/ Waldenström’s macroglobulinemia: a morphological and immunophenotypic study of the bone marrow. Mod Pathol 3:348, 1990. 122. Dutcher TF, Fahey JL: The histopathology of macroglobulinemia of Waldenström. J Natl Cancer Inst 22:887, 1959. 123. Hunter ZR, Manning RJ, Hanzis C, et al: IgA and IgG hypogammaglobulinemia in Waldenström’s macroglobulinemia. Haematologica 95:470, 2010. 124. Stone MJ, Bogen SA: Evidence-based focused review of management of hyperviscosity syndrome. Blood 119:2205, 2012. 125. Menke MN, Treon SP: Hyperviscosity syndrome. In Sekeres MA, Kalaycio M, Bolwell BJ, editors: Clinical malignant hematology, New York, 2007, McGraw-Hill, p 937. 126. Moulopoulos LA, Dimopoulos MA, Varma DG, et al: Waldenström macroglobulinemia: MR imaging of the spine and CT of the abdomen and pelvis. Radiology 188:669, 1993. 127. Kyle RA, Treon SP, Alexanian R, et al: Prognostic markers and criteria to initiate therapy in Waldenström’s macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenström’s Macroglobulinemia. Semin Oncol 30:116, 2003. 128. Dimopoulos MA, Kastritis E, Owen RG, et al: Treatment recommendations for patients with Waldenström macroglobulinemia (WM) and related disorders: IWWM-7 consensus. Blood 124:1404, 2014. 129. Kyle RA, Greipp PR, Gertz MA, et al: Waldenström’s macroglobulinaemia: a prospective study comparing daily with intermittent oral chlorambucil. Br J Haematol 108:737, 2000. 130. Dimopoulos MA, Alexanian R: Waldenström’s macroglobulinemia. Blood 83:1452, 1994. 131. Petrucci MT, Avvisati G, Tribalto M, et al: Waldenström’s macroglobulinaemia: results of a combined oral treatment in 34 newly diagnosed patients. J Intern Med 226:443, 1989. 132. Case DC, Jr, Ervin TJ, Boyd MA, et al: Waldenström’s macroglobulinemia: long-term results with the M-2 protocol. Cancer Invest 9:1, 1991. 133. Facon T, Brouillard M, Duhamel A, et al: Prognostic factors in Waldenström’s macroglobulinemia: a report of 167 cases. J Clin Oncol 11:1553, 1993. 134. Leblond V, Johnson S, Chevret S, et al: Results of a randomized trial of chlorambucil versus fludarabine for patients with Waldenström macroglobulinemia, marginal zone lymphoma, or lymphoplasmacytic lymphoma. J Clin Oncol 31:301, 2013. 135. Dimopoulos MA, Kantarjian H, Weber D, et al: Primary therapy of Waldenström’s macroglobulinemia with 2-chlorodeoxyadenosine. J Clin Oncol 12:2694, 1994. 136. Delannoy A, Ferrant A, Martiat P, et al: 2-Chlorodeoxyadenosine therapy in Waldenström’s macroglobulinaemia. Nouv Rev Fr Hematol 36:317, 1994. 137. Fridrik MA, Jäger G, Baldinger C, et al: First-line treatment of Waldenström’s disease with cladribine. Ann Hematol 74:7, 1997. 138. Liu ES, Burian C, Miller WE, et al: Bolus administration of cladribine in the treatment of Waldenström macroglobulinaemia. Br J Haematol 103:690, 1998. 139. Hellmann A, Lewandowski K, Zaucha JM, et al: Effect of a 2-hour infusion of 2-chlorodeoxyadenosine in the treatment of refractory or previously untreated Waldenström’s macroglobulinemia. Eur J Haematol 63:35, 1999. 140. Betticher DC, Hsu Schmitz SF, Ratschiller D, et al: Cladribine (2-CDA) given as subcutaneous bolus injections is active in pretreated Waldenström’s macroglobulinaemia. Swiss Group for Clinical Cancer Research (SAKK). Br J Haematol 99:358, 1997. 141. Dimopoulos MA, Weber D, Delasalle KB, et al: Treatment of Waldenström’s macroglobulinemia resistant to standard therapy with 2-chlorodeoxyadenosine: identification of prognostic factors. Ann Oncol 6:49, 1995. 142. Dimopoulos MA, O’Brien S, Kantarjian H, et al: Fludarabine therapy in Waldenström’s macroglobulinemia. Am J Med 95:49, 1993. 143. Foran JM, Rohatiner AZ, Coiffier B, et al: Multicenter phase II study of fludarabine phosphate for patients with newly diagnosed lymphoplasmacytoid lymphoma, Waldenström’s macroglobulinemia, and mantle-cell lymphoma. J Clin Oncol 17:546, 1999.

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Part VII  Hematologic Malignancies

144. Thalhammer-Scherrer R, Geissler K, Schwarzinger I, et al: Fludarabine therapy in Waldenström’s macroglobulinemia. Ann Hematol 79:556, 2000. 145. Dhodapkar MV, Jacobson JL, Gertz MA, et al: Prognostic factors and response to fludarabine therapy in patients with Waldenström macroglobulinemia: results of United States intergroup trial (Southwest Oncology Group S9003). Blood 98:41, 2001. 146. Zinzani PL, Gherlinzoni F, Bendandi M, et al: Fludarabine treatment in resistant Waldenström’s macroglobulinemia. Eur J Haematol 54:120, 1995. 147. Leblond V, Ben Othman T, Deconinck E, et al: Activity of fludarabine in previously treated Waldenström’s macroglobulinemia: a report of 71 cases. J Clin Oncol 16:2060, 1998. 148. Dimopoulos MA, Weber DM, Kantarjian H, et al: 2-Chlorodeoxyadenosine therapy of patients with Waldenström macroglobulinemia previously treated with fludarabine. Ann Oncol 5:288, 1994. 149. Lewandowski K, Halaburda K, Hellmann A: Fludarabine therapy in Waldenström’s macroglobulinemia patients treated previously with 2-chlorodeoxyadenosine. Leuk Lymphoma 43:361, 2002. 150. Popat U, Saliba R, Thandi R, et al: Impairment of filgrastim-induced stem cell mobilization after prior lenalidomidein patients with multiple myeloma. Biol Blood Marrow Transplant 15:718, 2009. 151. Leleu XP, Manning R, Soumerai JD, et al: Increased incidence of transformation and myelodysplasia/acute leukemia in patients with Waldenström macroglobulinemia treated with nucleoside analogs. J Clin Oncol 27:250, 2009. 152. Leleu X, Tamburini J, Roccaro A, et al: Balancing risk versus benefit in the treatment of Waldenström’s macroglobulinemia patients with nucleoside analogue based therapy. Clin Lymphoma Myeloma 9:71, 2009. 153. Treon SP, Kelliher A, Keele B, et al: Expression of serotherapy target antigens in Waldenström’s macroglobulinemia: Therapeutic applications and considerations. Semin Oncol 30:248, 2003. 154. Treon SP, Agus DB, Link B, et al: CD20-directed antibody-mediated immunotherapy induces responses and facilitates hematologic recovery in patients with Waldenström’s macroglobulinemia. J Immunother 24:272, 2001. 155. Gertz MA, Rue M, Blood E, et al: Multicenter phase 2 trial of rituximab for Waldenström macroglobulinemia (WM): an Eastern Cooperative Oncology Group study (E3A98). Leuk Lymphoma 45:2047, 2004. 156. Dimopoulos MA, Zervas C, Zomas A, et al: Treatment of Waldenström’s macroglobulinemia with rituximab. J Clin Oncol 20:2327, 2002. 157. Treon SP, Emmanouilides C, Kimby E, et al: Extended rituximab therapy in Waldenström’s macroglobulinemia. Ann Oncol 16:132, 2005. 158. Treon SP, Branagan AR, Hunter Z, et al: Paradoxical increases in serum IgM and viscosity levels following rituximab in Waldenström’s macroglobulinemia. Ann Oncol 15:1481, 2004. 159. Ghobrial IM, Fonseca R, Greipp PR, et al: Initial immunoglobulin M “flare” after rituximab therapy in patients with Waldenström macroglobulinemia: an Eastern Cooperative Oncology Group study. Cancer 101:2593, 2004. 160. Dimopoulos MA, Anagnostopoulos A, Zervas C, et al: Predictive factors for response to rituximab in Waldenström’s macroglobulinemia. Clin Lymphoma 5:270, 2005. 161. Treon SP, Hansen M, Branagan AR, et al: Polymorphisms in FcγRIIIA (CD16) receptor expression are associated with clinical responses to rituximab in Waldenström’s macroglobulinemia. J Clin Oncol 23:474, 2005. 162. Dimopoulos MA, Anagnostopulos A, Kyrtsonis MC, et al: Treatment of relapsed or refractory Waldenström’s macroglobulinemia with bortezomib. Haematologica 90:1655, 2005. 163. Chen CI, Kouroukis CT, White D, et al: Bortezomib is active in patients with untreated or relapsed Waldenström’s macroglobulinemia: a phase II study of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 25:1570, 2007. 164. Weber DM, Dimopoulos MA, Delasalle K, et al: 2-Chlorodeoxyadenosine alone and in combination for previously untreated Waldenström’s macroglobulinemia. Semin Oncol 30:243, 2003.

165. Treon SP, Branagan AR, Ioakimidis L, et al: Long term outcomes to fludarabine and rituximab in Waldenström’s macroglobulinemia. Blood 113:3673, 2009. 166. Tam CS, Wolf MM, Westerman D, et al: Fludarabine combination therapy is highly effective in first-line and salvage treatment of patients with Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma 6:136, 2005. 167. Hensel M, Villalobos M, Kornacker M, et al: Pentostatin/ cyclophosphamide with or without rituximab: an effective regimen for patients with Waldenström’s macroglobulinemia/lymphoplasmacytic lymphoma. Clin Lymphoma Myeloma 6:131, 2005. 168. Dimopoulos MA, Anagnostopoulos A, Kyrtsonis MC, et al: Primary treatment of Waldenström’s macroglobulinemia with dexamethasone, rituximab and cyclophosphamide. J Clin Oncol 25:3344, 2007. 169. Buske C, Hoster E, Dreyling MH, et al: The addition of rituximab to front-line therapy with CHOP (R-CHOP) results in a higher response rate and longer time to treatment failure in patients with lymphoplasmacytic lymphoma: results of a randomized trial of the German Low-Grade Lymphoma Study Group (GLSG). Leukemia 23: 153, 2009. 170. Treon SP, Hunter Z, Branagan A: CHOP plus rituximab therapy in Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma 5:273, 2005. 171. Ioakimidis L, Patterson CJ, Hunter ZR, et al: Comparative outcomes following CP-R, CVP-R and CHOP-R in Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma 9:62, 2009. 172. Rummel M, Niederle N, Maschmeyer G, et al: Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet 381:1203, 2013. 173. Treon SP, Hanzis C, Tripsas C, et al: Bendamustine therapy in patients with relapsed or refractory Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma Leuk 211:133, 2011. 174. Dimopoulos MA, Hamilos G, Efstathiou E, et al: Treatment of Waldenström’s macroglobulinemia with the combination of fludarabine and cyclophosphamide. Leuk Lymphoma 44:993, 2003. 175. Tamburini J, Levy V, Chateilex C, et al: Fludarabine plus cyclophosphamide in Waldenström’s macroglobulinemia: results in 49 patients. Leukemia 19:1831, 2005. 176. Treon SP, Ioakimidis L, Soumerai JD, et al: Primary therapy of Waldenström’s macroglobulinemia with bortezomib, dexamethasone and rituximab. J Clin Oncol 27:3830, 2009. 177. Ghobrial IM, Matous J, Padmanabhan S, et al: Phase II trial of combination of bortezomib and rituximab in relapsed and/or refractory Waldenström’s macroglobulinemia. Blood 112:832, 2008. 178. Agathocleous A, Rohatiner A, Rule S, et al: Weekly versus twice weekly bortezomib given in conjunction with rituximab in patients with recurrent follicular lymphoma, mantle cell lymphoma, and Waldenström macroglobulinemia. Br J Haematol 151:346, 2010. 179. Dimopoulos MA, García-Sanz R, Gavriatopoulou M, et al: Primary therapy of Waldenström macroglobulinemia (WM) with weekly bortezomib, low-dose dexamethasone, and rituximab (BDR): long-term results of a phase 2 study of the European Myeloma Network (EMN). Blood 122:3276, 2013. 180. Treon SP, Palomba ML, Tripsas CK, et al: Ibrutinib in previously treated patients with Waldenström’s macroglobulinemia. Paper presented at the 8th International Workshop on Waldenström’s Macroglobulinemia, London, UK, August 14–16, 2014. Abstract 91. 181. Ghobrial IM, Witzig TE, Gertz M, et al: Long-term results of the phase II trial of the oral mTOR inhibitor everolimus (RAD001) in relapsed or refractory Waldenström macroglobulinemia. Am J Hematol 89:237, 2014. 182. Treon SP, Tripsas CK, Meid K, et al: Prospective, multicenter study of the mTOR inhibitor everolimus (RAD001) as primary therapy in Waldenström’s macroglobulinemia. Blood 122:1822, 2013. 183. Treon SP, Hanzis C, Manning RJ, et al: Maintenance rituximab is associated with improved clinical outcome in rituximab naïve patients with Waldenström’s macroglobulinemia who respond to a rituximab containing regimen. Br J Haematol 154:357, 2011.

Chapter 87  Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma 184. Rummel MJ, Lerchenmüller C, Greil R, et al: Bendamustine-rituximab induction followed by observation or rituximab maintenance for newly diagnosed patients with waldenström’s macroglobulinemia: results from a prospective, randomized, multicenter study (StiL NHL 7-2008). Blood 120:2739, 2012. 185. Kyriakou C, Canals C, Sibon D, et al: High-dose therapy and autologous stem-cell transplantation in Waldenström macroglobulinemia: the Lymphoma Working Party of the European Group for Blood and Marrow Transplantation. J Clin Oncol 28:2227, 2010. 186. Kyriakou C, Canals C, Cornelissen JJ, et al: Allogeneic stem-cell transplantation in patients with Waldenström macroglobulinemia: report from the Lymphoma Working Party of the European Group for Blood and Marrow Transplantation. J Clin Oncol 28:4926, 2010. 187. Owen RG, Kyle RA, Stone MJ, et al: Response assessment in Waldenström macroglobulinemia. Br J Haematol 160:171, 2013. 188. Treon SP, Yang G, Hanzis C, et al: Attainment of complete/very good partial response following rituximab based therapy is an important determinant to progression-free survival and is impacted by polymorphisms in FCGR3A in Waldenström macroglobulinaemia. Br J Haematol 154:223, 2011. 189. Strauss SJ, Maharaj L, Hoare S, et al: Bortezomib therapy in patients with relapsed or refractory lymphoma: potential correlation of in vitro sensitivity and tumor necrosis factor alpha response with clinical activity. J Clin Oncol 24:2105, 2006. 190. Varghese AM, Rawstron AC, Ashcroft J, et al: Assessment of bone marrow response in Waldenström’s macroglobulinemia. Clin Lymphoma Myeloma 9:53, 2009. 191. Ciccarelli BT, Yang G, Hatjiharissi E, et al: Soluble CD27 is a faithful marker of disease burden and is unaffected by the rituximab induced

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