What do I need to know about immunoglobulin light chain (AL) amyloidosis?

Blood Reviews 26 (2012) 137–154

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REVIEW

What do I need to know about immunoglobulin light chain (AL) amyloidosis? Angela Dispenzieri ⁎, Morie A. Gertz 1, Francis Buadi 2 Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States

a r t i c l e

i n f o

Keywords: Amyloidosis Multisystem disease Monoclonal gammopathy Prognosis Transplantation

a b s t r a c t Immunoglobulin light chain (AL) amyloidosis is the most common acquired systemic amyloidoses. Its presentation is often insidious and progressive, which may delay diagnosis. The interval between first symptoms and actual diagnosis along the intrinsic heterogeneity of tissue tropism create a wide spectrum of presentations, both in terms of scope and depth of symptoms and signs and functional status of patients. In this review, the authors review the pathogenesis, diagnosis and differential diagnosis of AL amyloidosis along with the prognosis and state-of-the-art management for patients with this affliction. © 2012 Elsevier Ltd. All rights reserved.

1. Introduction Immunoglobulin light chain amyloidosis (AL) is a low tumor burden plasma cell disorder characterized by deposition of insoluble fibrils composed of immunoglobulin light chains. Without treatment, AL has an inexorable progressive course due to uncontrolled tissue damage (Fig. 1A). Although AL is the most common form of systemic amyloidosis, with an incidence of approximately 1 case per 100,000 person-years in Western countries, 1 there are other forms of systemic amyloidosis (Table 1). 2 Typing the amyloid is imperative since treatment strategies are different depending on the source of precursor protein. 3 In the case of AL amyloidosis, the precursor protein is bone marrow plasma cell derived immunoglobulin light chains, which is quite different from the case of ATTR, wherein the precursor protein—transthyretin—is made in the liver. 2. Pathogenesis The mechanism of amyloid formation is not completely understood, but amyloid is formed when the structure of a native protein is converted into a predominantly antiparallel β-sheet secondary structure which is conducive to aggregation in tissues in the form of fibrils that we recognize as amyloid on electron microscopy and on light microscopy with stains like Congo Red. In the case of AL, not all immunoglobulin light chains are equally amyloidogenic since only 10 to 15% of patients with myeloma have co-existing amyloidosis at diagnosis, 4 and only 1% of patients with active myeloma go on to develop AL. 5 The intrinsic property of the B-cell and plasma cell

⁎ Corresponding author. Tel.: + 1 507 284 2176; fax: + 1 507 266 4972. E-mail addresses: [email protected] (A. Dispenzieri), [email protected] (M.A. Gertz), [email protected] (F. Buadi). 1 Tel.: + 1 507 284 2865; fax: + 1 507 266 4972. 2 Tel.: + 1 507 284 2017. 0268-960X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.blre.2012.03.001

niches to generate immunoglobulin diversity through a large immunoglobulin variable gene repertoire, programmed recombination, and somatic mutation make immunoglobulins very suitable amyloid precursor proteins. The distribution of immunoglobulin light chain variable gene usage by bone marrow plasma cells is expected to be 3:1 κ to λ in the normal population. Despite this, the number of AL cases favors λ to κ by 2:1, which supports the concept that germline λ is intrinsically more amyloidogenic than κ (Table 2). Moreover, certain immunoglobulin variable genes (IGLV and IGKV) appear to be more amyloidogenic than others given their frequency of usage in the general population as compared to patients with AL. 6,7 For example, IGLV6 family usage is rare among other B-cells and Bcell neoplasms, but comprises approximately 30% of λ restricted AL cases. IGLV3-1 gene usage is higher than expected and usage of genes from the IGKV2 family is less common in AL than expected. 8 Risk factors for amyloid formation have included specific modifications to the immunoglobulin light chain. 9–13 It is believed that AL immunoglobulin light chain internalizes into cells and traffics into lysosomes. Macrophages and their lysosomes are implicated in amyloid formation at target tissues 14–16 For example, human mesangial cells exposed to AL immunoglobulin light chain not only form amyloid fibrils in vitro but they become transformed to a macrophage-like phenotype including the acquisition of lysosomes. 17 Amyloid fibrils found in human tissues are not merely comprised of pure amyloid precursor protein. Other proteins are found in the amyloid deposits, most commonly serum amyloid protein (SAP), apolipoprotein E (ApoE), apolipoprotein A1 (ApoA1), and apolipoprotein A4 (ApoA4). 18 Little is known about why amyloid targets specific tissues in one patient versus another. There are a few relatively small series evaluating whether a specific IGKV and IGLV gene used predetermines tissue tropism (Fig. 2), 6,19–23 but these have produced inconsistent results, potentially due to the small number of sequences included, differences in technique including primer selection, patient

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A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

A

1

Monoclonal Plasma cells

2

Immunoglobulin free light chains

3

Amyloid fibrils

Tissue damage

B

Hematologic response

Organ response

Toxicity monitoring and management

Fig. 1. Simplified cartoon of AL pathogenesis with emphasis on management issues. Clonal bone marrow plasma cells make soluble immunoglobulin free light chains which circulate in the blood and extravascular space. Through uncertain mechanisms, these free light chains form organized aggregates (amyloid fibrils) that deposit within the microvasculature and interstitium of various tissues, most notably the kidney, heart, liver, skin, nerves, intestinal tract, muscle, and lungs. When considering therapy, response assessment must consider both halves of the diagram, with the understanding that chemotherapy can be discontinued before organ response as long as hematologic response achieved.

populations, and analyses performed. It had been dogma that IGLV6 always involved the kidneys, but later studies have shown that IGLV6 cases can involve the heart. 19,20,23 3. Diagnosis There are four essential steps in diagnosing amyloidosis: 1) consider the diagnosis; 2) make the diagnosis by tissue biopsy; 3) determine the precursor protein; and 4) define the extent of involvement. One of the biggest challenges for patients with AL is having the diagnosis considered in timely fashion. Often it is a physician other than a hematologist/oncologist who is charged with contemplating the diagnosis. Although features like periorbital purpura and macroglossia are pathognomonic, they are rare and cannot be relied upon to be the sole triggers for considering a diagnosis of AL. Hematologists should not be misled by a stable monoclonal protein in a patient followed for monoclonal gammopathy of undetermined significance or smoldering myeloma, who reports increased fatigue, into believing that the clonal plasma disorder is not the source of the patient's status without seriously considering the possibility of AL. The most commonly affected organs resulting in symptoms are the heart, kidneys, skin, peripheral nerves, autonomic nerves, and liver and their respective means of presentation are: 1) normal ejection fraction with diastolic dysfunction, left ventricular hypertrophy with low voltage electrocardiogram; 2) nephrotic syndrome with preserved glomerular filtration rate; 3) purpura most notably around the eyes and neck; 4) small fiber peripheral neuropathy characterized by dysesthesia; 5) orthostatic hypotension; 6) hepatomegaly often with a cholestatic rise in liver function tests Although the gastrointestinal tract is commonly biopsy positive, it is relatively uncommon for patients to have symptoms referable to it. A diagnosis

of pulmonary involvement is rare since no formal criteria exist. Amyloid arthropathy occurs in about 2% of patients, whereas carpal tunnel syndrome is quite common, occurring in 25%. 24 The dominant symptomatic organ system involved varies among different practices (Fig. 3). 25 Once a diagnosis of AL is suspected, a monoclonal protein in the serum and the urine should be sought and a tissue biopsy performed. Screening for a monoclonal protein is done by serum immunoglobulin free light chain measurement and immunofixation studies of the serum and urine. 26 Although an important part of the work-up, serum and 24-hour urine protein electrophoresis alone are insufficient as screening tools. Among patients with AL amyloidosis, the sensitivity of serum protein electrophoresis for detecting a monoclonal protein is only 66%, whereas the sensitivity of serum immunofixation is 74%, and serum immunoglobulin free light chain assay is 88%. The sensitivity for detecting a monoclonal protein further increases to 94% if one combines all three serum tests and rises to 98% if urine immunofixation is added. 26 The diagnostic biopsy may be of the tissue causing symptoms—e.g. heart or kidney—or of a more accessible tissue, like fat or bone marrow. The sensitivity of a biopsy of a symptomatic organ is higher than that of the more accessible tissues, i.e. more than 95% for symptomatic tissue, 75–80% for fat, and 50–65% for bone marrow. 27 A diagnosis of amyloidosis is not made by hematoxylin and eosin staining alone; special stains like Congo Red, Thioflavin T or sulfated Alcian blue are required. Congo Red avidity is not sufficient; apple-green birefringence under polarized light is essential for a diagnosis. Electron microscopy is also helpful to identify the 8–11 nanometer non-branching fibrils. Once a diagnosis of amyloidosis is made, typing is required by subjecting the amyloid to direct sequencing, immunogold, immunofluorescence or immunohistochemistry. The presence of a serum or

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139

Table 1 Classification of the most common amyloidoses. Type of amyloidosis

Precursor protein component

Clinical presentation

AL amyloidosisa (previously referred to as primary amyloidosis) AH amyloidosis AA amyloidosis (previously referred to as secondary amyloidosis)

κ or λ immunoglobulin light chain γ, μ, α immunoglobulin heavy chain Serum amyloid A protein

LECT2 ATTR amyloidosis b Mutated transthyretin (commonly referred to as familial amyloid polyneuropathy) Wild-type TTRb (senile amyloidosis) β2-microglobulin amyloidosis (associated with long-term dialysis) Aβ amyloidosis Other hereditary amyloidosis A fibrinogen (also called familial renal amyloidosis) Lysozyme Apolipoprotein A-I AGelsolin

Leukocyte chemotactic factor 2

Systemic or localized Systemic or localized Renal presentation most common; associated with chronic inflammatory conditions; typically acquired, but hereditary in case of familial periodic fever syndromes Renal presentation; acquired

Mutant TTR Normal transthyretin β2-microglobulin Aβ protein precursor

Hereditary; peripheral neuropathy, autonomic neuropathy, vitreous opacities, and/or cardiomyopathy Restrictive cardiomyopathy; carpal tunnel syndrome Carpal tunnel syndrome, arthropathy large joints Alzheimer disease

Fibrinogen α-chain Lysozyme A-I Apolipoprotein Gelsolin

Renal presentation Renal presentation most common Renal presentation most common Cranial neuropathy

a AL amyloidosis is the only form of amyloidosis that is secondary to a clonal plasma cell disorder. AL amyloidosis can be associated with multiple myeloma in approximately 10% of patients. b TTR refers to transthyretin, which is commonly referred to as prealbumin.

urine monoclonal protein does not assure a diagnosis of AL and may lead to misdiagnosis in as many as 10% of cases. 28,29 In the 21st century, the preferred method of typing the amyloid protein from tissues is mass spectrometry. 30,31 4. Defining disease extent A thorough assessment of extent of involvement is required in order to develop a treatment plan. 32 It is at this time that the distinction between localized and systemic AL is made. The designation ‘localized’ applies to those cases of AL in which the precursor protein (the immunoglobulin light chain) is made at the site of amyloid deposition 33–35 and is typically not associated with a detectable circulating monoclonal protein in the serum or urine. The mere absence of a monoclonal protein does not mean that a patient has a localized form of amyloid. The classic examples of localized amyloidosis are tracheobronchial, urinary tract, cutaneous, lymph node, and nodular cutaneous involvement. At the Mayo Clinic 7% of amyloidosis cases falls into one of these classic distributions. Establishing the extent of disease in systemic AL is achieved by a thorough review of systems and physical examination and by performing the tests in Table 3. An amyloid review of system includes ascertaining whether any of the following exists: fatigue, weight loss, peri-orbital purpura, peri-orbital edema, jaw claudication, xerostomia, swollen submandibular nodes, macroglossia, orthostasis, change in bowel habit, dyspnea on exertion, paroxysmal nocturnal dyspnea, palpitations, chest pain, syncope, leg or hip claudication, paresthesias

or dysesthesias in the hands or feet, bleeding, or spooning or splitting of nail beds. Physical exam mirrors the review of systems. The definitions of organ involvement are listed in Table 4. Once clarifications about disease extent are made, one can embark on a treatment and follow-up plan. As will be discussed in the section on prognosis, understanding the extent of cardiac involvement is paramount for risk stratification and deciding about the therapeutic window of a given therapy. The echocardiogram had been one of the most important tests among patients with amyloidosis. As the amyloid community gains experience with soluble cardiac markers like troponin and NT-proBNP, the relatively low sensitivity of echocardiographic changes becomes more evident. 36,37 The earliest echocardiographic finding is diastolic, 38 but a variety of cardiac abnormalities may be seen in these patients including left ventricular hypertrophy, 39 left ventricular outflow obstruction, 40 right ventricular dysfunction, 41,42 right ventricular dilatation, 43 atrial dysfunction., 44 abnormal strain imaging and strain rate imaging, 45–47 reduced ejection time, 48 late gadolinium enhancement and abnormal gadolinium kinetics on cardiac magnetic resonance imaging, 49,50 and rhythm and conduction abnormalities. 51 As the disease progresses, progressive left ventricular wall thickening with myocardial hyperechogenicity, biatrial enlargement, thickened atrial septum and valve leaflets, and pericardial effusion can be seen. Doppler myocardial images can detect early systolic dysfunction even among those amyloid patients who have no evidence of cardiac amyloid by standard echocardiography. 46 The mean of either systolic strain rate or systolic strain from 6 middle segments can detect early

Table 2 Immunoglobulin variable gene usage in patients with AL. Ref

19 20 6 21 22 23

Total Median Expected6,7

N

39 60 55 60 191 53 455

λ cases

% of λ cases

κ cases

% of κ cases

n

IGLV1

IGLV2

IGLV3

IGLV4

IGLV6

n

IGKV1

32 48 55 32 139 42 348

31 30 15 22 29 26

16 15 16 34 22 17

19 17 47 28 26 26

0 0 2 0 1 0

34 38 20 16 22 31

7 12 0 26 51 11 107

100 100 0 77 84 100

28 26

16 24

26 40

0 2

27 4

100 64

IGKV refers to a family of immunoglobulin kappa variable genes. IGLV refers to a family of immunoglobulin lambda variable genes. Not all rows add up to 100% due to an occasional patient with IGLV family not included in the table.

IGKV2

IGKV3

IGKV4

0 0 0 4 2 0

0 0 0 0 2 0

0 0 0 19 12 0

0 18

0 9

0 9

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

Number of cases of each sequenced IGV that is renal or cardiac dominant

140

18

% IGV Renal

% IGV Cardiac

16 14 12 10 8 6 4 2

Series from Bellavia et al 2011, n=21 renal dominant N=17 cardiac dominant

Series from Comenzo et al 1999, n=22 renal dominant N=7 cardiac dominant

LV 1 LV 2 IG LV 3 IG LV 6 IG K V1 IG

IG

LV 1 LV 2 IG LV 3 IG LV 6 IG K V1 IG

IG

IG

IG

LV 1 LV 2 IG LV 3 IG LV 6 IG K V1 IG K V3

0

Series from Comenzo et al 2001, N=31 renal dominant N=15 cardiac dominant

Fig. 2. Disparate reports regarding immunoglobulin variable gene family (IGLV or IGKV) usage and organ involvement. The figure is arranged by report with each bar illustrating frequency of usage of a given gene family is ether dominant cardiac (white) or dominant renal (gray).

cardiac involvement and further cull out patients with more advanced cardiomyopathy. 47 The role of cardiac MRI is not yet established in terms of prognosis, but the presence of delayed gadolinium enhancement seen on T1weighted images—predominantly subendocardially—is relatively sensitive for amyloid involvement and is frequently becoming the test prompting suspicion of a diagnosis of amyloidosis. 49,50 5. Prognosis The specific organs and the extent of organ involvement vary considerably in patients with AL so identification of prognostic factors is important. The major prognostic factors can be categorized into five major categories: 1) referral bias; 2) cardiac factors; 3) factors directly related to the clone; 4) number of organs involved; and 5) other factors. 5.1. Referral bias and cardiac parameters as prognostic factors Referral bias and the ability to survive for at least a year are two under recognized prognostic factors in this patient population. In 1995, Kyle reported that the median overall survival was nearly double for those patients seen at Mayo Clinic more than 30 days after their diagnosis as compared to those seen within 30 days (24 months

60

Pavia, Italy

% of patients

Mayo Clinic, USA

40

20

versus 13 months) 27 and that risk factors for death were different during the first year and after the first year. 52 More recent data from our institution (Fig. 4A) illustrate what the magnitude of the early mortality problem in this disease is. 53 Over the past 40 years, the proportion of patients dying within 6 months of diagnosis remains fixed at about 35%, with the least improvement over time for these sickest patients (Fig. 4B). Patients with AL can be parsed into prognostic groups based on cardiac biomarkers, most notably troponin T and NT-proBNP. 54–57 When outcomes are examined based on both period of diagnosis and on Mayo Stage, 54,55 one can see that marked improvements have occurred among patients with stage I disease. 53 Among the lowest risk AL patients, the median OS was not reached for the two most recently diagnosed cohorts in contrast to a median overall survival of 2.3 years (95% confidence interval, 1.4–3.3) for those diagnosed between 1987 and 1996

Table 3 Tests required for diagnosis and staging of AL. All patients Tissue biopsy Congo red stain with apple green birefringence Type amyloid protein Blood tests Alkaline phosphatase, bilirubin, creatinine, albumin, uric acid Troponin, N-terminal brain natriuretic peptide (or brain natriuretic peptide) Immunoglobulin free light chain, serum protein electrophoresis with immunofixation Factor X level 24 hour urine Protein electrophoresis with immunofixation Cardiac imaging Echocardiogram with tissue Doppler imaging to assess for heart size and diastolic dysfunction Electrocardiogram As clinically indicated

0 Kidney

Heart

Liver

PNS

GI

Fig. 3. AL amyloidosis organ involvement and symptomatology. Dominant organ involvement at presentation. Based on data from: Palladini G, Kyle RA, Larson DR, Therneau TM, Merlini G, Gertz MA. Multicentre versus single center approach to rare diseases: the model of systemic light chain amyloidosis. Amyloid. 2005;12:120–126.

Diagnostic imaging of liver and spleen Fecal fat measurements Serum carotene levels Nerve conduction studies Serum amyloid P scan MRI heart Holter monitor

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Table 4 AL amyloidosis hematologic response criteria.a Source: Data are based on references Gertz et al.87 and Palladini et al.95. Response type

Abbreviation

Criteria

Difference between 2005 and 2011 criteriab

Complete response

CR

Very good partial response Partial response

VGPR PR

Negative serum and urine IFE and Normal serum immunoglobulin κ/λ FLC ratio dFLC b 40 mg/Lb dFLC decrease of greater than equal to 50%b

No response Progression

NR Prog

Mandatory bone marrow removed from response criteria New response criterion Serum M-spike relegated to secondary status and used only if no measurable involved serum free light chain No change No change

Less than a partial response From CR, any detectable monoclonal protein or abnormal free light chain ratio (light chain must double) From PR, serum immunoglobulin free light chain increase of 50% which also must be to a level of greater than 100 mg/L, Or a 50% increase in serum M protein which must also be to a level greater than 5 g/L, Or a 50% increase in urine M protein which also must be to a level greater than 200 mg/day (a visible peak must be present)

dFLC, difference between involved and uninvolved serum immunoglobulin free light chain, which means that if patient has a lambda FLC of 300 mg/L and a kappa of 20 mg/L, the dFLC would equal 280 mg/L. a The final version of the latest International Consensus Response criteria have not been finalized. b A difference between the involved and uninvolved FLC (dFLC) of 50 mg/L was defined as assessable or measurable for response.

(Fig. 4C). Among patients with stage II disease, the median OS was not reached for the most recent group and was 2.4 years for the 1996–2004 and 0.9 year for the 1987–1996 (Fig. 4D). Finally, among stage III patients, the most recent group had a median OS of 1.0 year compared with 0.4 year for the two other periods (Fig. 4E). More refined ways of predicting early death have been developed. 53 Using receiver operator curves, a system using the following cut points: troponin T greater than 0.01 mcg/L; NT-proBNP greater than 4200 ng/L; and uric acid greater than 7.8 mg/dL has been developed. For each test over the threshold a point is assigned, resulting in 4 groups (0, 1, 2, or 3 risk factors) with 1 year mortality rates of 19%, 37%, 61%, and 80% (Fig. 4F). The potential advantage of blood tests for assessing cardiac status includes the reproducibility of the assays in contrast to the interobserver variability of echocardiography, their ease of testing, and their relatively low cost. Disadvantages of the soluble biomarkers include the number of reagents available. For example, some facilities do not offer NT-proBNP or troponin T but rather only offer BNP and troponin I. A touted disadvantage of cardiac biomarkers in general is that they rise in the setting of renal failure, which may be a problem for serial measurements in the context of fluctuating glomerular filtration rates. We would argue that this ‘susceptibility’ is an asset in terms of prognostication since these markers provide a composite view of the patient providing information about two organ systems. Aside from troponin T and NT-proBNP, there are data supporting the prognostic value of troponin I, BNP, and high-sensitivity troponin T. 23,36,50,54,55,58–60 There may be a role for using high-sensitivity troponin T alone in lieu of the troponin T and the NT-proBNP as a prognostic marker in the future. 61 General disadvantages of the different assays include a relative lack of sensitivity of troponin I, no current widespread clinical availability of high sensitivity troponin T in the U.S., a lack of standardization of the various BNP assays, and inferior performance of NT-proBNP as compared to BNP in the setting of renal dysfunction. 62–64 Aside from blood tests, the clinical history is an important prognosticator. AL patients presenting with florid CHF or syncope have median survivals of 4–6 months. 65,66 Cardiovascular magnetic resonance (CMR) is also proving to be of use in diagnosing and predicting prognosis in patients with AL amyloidosis, but it is an early science. Two small studies have evaluated the prognostic value of CMR and found that gadolinium kinetics, 49 but not late gadolinium enhancement, 49,50 predict for overall survival. 49 The 2 minute postgadolinium intramyocardial T1 difference between subepicardium and subendocardium predicts mortality with 85% accuracy at a threshold value of 23 ms (the lower the difference the worse the

prognosis). 49 Late gadolinium enhancement volume was positively correlated with serum level of B-type natriuretic peptide (BNP; R = 0.64, p b or = 0.001), and in multivariate analysis, late gadolinium enhancement volume proved the strongest independent predictor of BNP. 50 5.2. Plasma cell clone and prognosis The observation that the size of the underlying plasma cell clone was prognostic was made in 1975. 67 Patients with coexisting multiple myeloma, which was largely defined based on bone marrow plasmacytosis, had inferior overall survival rates; the respective median survival rates with and without coexisting multiple myeloma were: at 1 year, 26% and 54%; and at 5 years, 3% and 17%. This observation has withstood the test of time. 65,66 Bone marrow plasmacytosis, the proliferative rate of the bone marrow plasma cells, and the presence of circulating plasma cells are all adverse prognostic markers for overall survival. 56,57,68 The presence of light chains in the urine was also noted to be an adverse prognostic factor for patients with AL. 69,70 Whether this is a function of “tumor burden” or renal damage is not clear. The absolute level of serum immunoglobulin free light chains has also been reported to be prognostic.71–73 The presence of translocation 11;14 appears to be an adverse prognostic factor in one small series. 74 If validated this is an important observation since the translocation 11;14 is found in 40– 50% of patients with AL amyloidosis. 74,75 Preliminary work assessing for elevated levels of cyclin D1 would support this finding. 76 Attempts at analyzing overall survival based on IGKV and IGLV usage have given disparate results. In one series, overall survival was better in patients whose amyloid contained product from IGVL6 compared to those with IGLV1 + IGLV2 + IGLV3. 19 In contrast, in another series, overall survival was better in patients with IGVK1 or IGVL1 gene usage than patients with IGLV2–3 or IGLV6 gene usage. 23 These observations were limited by small sample size and a lack of multivariate analyses. 54–58,77 5.3. Number of organs involved are prognostic It has been long recognized that the more organs involved, the worse the prognosis for the patient regardless of the treatment. 78,79 Fig. 5 illustrates the impact that the number of organs involved by amyloidosis based on clinical parameters has on overall survival in 270 patients undergoing ASCT. Whereas median survival had not been reached at 6 years in those patients with one affected organ, the

142

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

A

Diagnosis period

100

1967-76 1977-86 1987-96 1997-06

Percent survival

80 60

B

5 yr OS

Stage I, N=127 Stage II, N=182 Stage III, N=174

~11% ~18% ~20% ~28%

40 20 0

All patients 0

25

50

75

100

125

150

Follow up from Diagnosis (mo)

1987-1996, n=60 1997-2003, n=45 2004-2006, n=22

C

D

1987-1996, n=49 1997-2003, n=61 2004-2006, n=72

Stage I

Stage II

F Stage III

1987-1996, n=54 1997-2003, n=55 2004-2006, n=65

% dead at 1 year

E

N=

170

128

93

49

Fig. 4. Long term outcomes of newly diagnosed AL patients over time and according cardiac risk factors. A. Improvement in overall survival among 2117 newly diagnosed AL patients seen at the Mayo Clinic from 1967 to 2006. B: Overall survival (OS) from diagnosis among 491 patients with available laboratory data with newly diagnosed AL seen at the Mayo Clinic between 1987 and 2006, grouped according to the cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) staging system.54 The staging system uses a cutoff value for NT-proBNP of less than 332 ng/L and a cutoff value for cTnT of less than 0.035 μg/L. Depending on whether values were both low, high for only one, or high for both, patients were classified as having stage I, II, or III disease, respectively. The median OS from diagnosis for patients in stages I, II, and III was 4.0, 2.4, and 0.5 years, respectively (P b .001). C, D, E: Overall survival from diagnosis among patients in prognostic stages I, II, and III, respectively, with each stage divided into 3 groups according to the date of diagnosis (1987–1996; 1996–2004; and 2004–2006). Stage 1, both below biomarkers below cut-off; Stage 2, one of the two biomarkers below cut-off; and Stage 3, both biomarkers above cut-offs. Cut-offs troponin T b 0.035 mcg/L and NT-proBNP b 332 ng/L (39 pmol/L). F. Likelihood of death at 1 year. Using receiver operator curves, a system using the following cut points: troponin T greater than 0.01 mcg/L; NT-proBNP greater than 4200 ng/L; and uric acid greater than 7.8 mg/dL. For each test over the threshold a point is assigned, resulting in 4 groups (0, 1, 2, or 3 risk factors) with 1 year mortality rates of 19%, 37%, 61%, and 80%. Modified from Kumar, S. K., M. A. Gertz, et al. (2011). “Recent improvements in survival in primary systemic amyloidosis and the importance of an early mortality risk score.” Mayo Clin Proc 86(1): 12–18.

respective median survival rates for patients with two and three affected organs, respectively, were 55 months and 25.5 months. 80 In a proportional hazards model, overall survival is associated with the number of organs involved and the free immunoglobulin light-chain protein level before treatment. 71 Delineation of the extent of organ involvement rather than merely the presence or absence or organ involvement is supplanting the current system of counting organs. The cardiac biomarker system offers a viable alternative since elevations reflect not only cardiac dysfunction, but also renal dysfunction. 54–56 Another motivation for migrating away from merely counting the number of organs involved is that outcomes vary not only due to extent of involvement, but also based on organ type. 27,69 In a cohort of 474 patients with AL seen at the Mayo Clinic between 1981 and 1992 within 30 days of diagnosis, the respective median overall survival for patients with congestive

heart failure, orthostatic hypotension, nephrotic syndrome, and peripheral neuropathy was 4, 12, 16, and 28 months, while the median survival of the entire group was 13.1 months and the 5-year survival was 7% (Fig. 6). 5.4. Other prognostic factors Several other important prognostic factors include weight loss, 69 male gender, 24 Howell–Jolly bodies, 81 beta-2 microglobulin, 82,83 123I-labeled serum amyloid P component extravascular retention, 84,85 and uric acid. 86 Serum amyloid P (SAP) component binds to amyloid. SAP scintigraphy is used to evaluate the extent and distribution of amyloid. Two studies demonstrate the prognostic utility of the extravascular retention of 123-I-SAP after 24 h in patients with AL. 84,85 Hachulla and colleagues studied 24 patients

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

80

1 organ

60

40

2 organs ≥3 organs

20

0 0

20

40

60

80

100

120

Months Fig. 5. The number of affected organs predicts for outcome in 270 patients undergoing autologous stem cell transplant. Modified from: Gertz MA, Lacy MQ, Dispenzieri A, Hayman SR, Kumar S. Transplantation for amyloidosis. Curr Opin Oncol. 2007;19:136–141.

with AL amyloidosis and found that 24 hour tissue retention was elevated in all patients. In addition, the mean survival in patients with tissue retention greater than 50% was 11.3 months versus 24.5 months in patients with levels less or equal to 50%. 85 Similarly, Hazenberg and colleagues studied the extravascular retention of 123I-SAP at 24 h in 80 patients with AL amyloidosis. 84 They found that the extravascular retention of 123-I-SAP after 24 h was strongly associated with the number of organs involved. On multivariate analysis, both cardiac involvement (hazard ratio, 3.9; 95% CI, 2.0–7.8) and extravascular retention of 123-I-SAP after 24 h of greater than 50% (hazard ratio, 2.0; 95% CI, 1.1–3.9) were independent predictors of survival. The authors concluded that although this measurement is prognostic, its sensitivity is only 61%. 6. Assessing response to treatment

serum and urine M-proteins more akin to monoclonal gammopathy of undetermined significance than myeloma, 24 meaningful hematologic response assessment had not been feasible in the majority of patients until the advent of the serum immunoglobulin free light chain assay. 71,88,89 Moreover, since these patients do not typically die due to bone marrow crowding from high “tumor-burden,” the major focus for response had been improvement in organ function rather than hematologic response (Fig. 1B), despite the recognition that hematologic response predicts for organ response. 79,90 Organ response is a time dependent factor with the median time to organ response of 1 year in the era of alkylator therapy with organ response continuing long after cessation of chemotherapy among those fortunate enough to respond. 91 Organ responses may occur more rapidly using proteasome inhibitors, 92 but the paradigm gearing initial treatment to achieve hematologic response rather than organ response is still important. In addition, quantifying organ response is an imperfect science. There are amyloid abnormalities including macroglossia, purpura, intestinal and pulmonary involvement for which no response criteria exist, and for those where criteria do exist, especially cardiac, measurement was not always reproducible. The emerging use of the soluble cardiac biomarker, N-terminal-pro B-type natriuretic peptide (NT-proBNP) has proved to be a helpful gage of cardiac response. 58,92

A 1.0 0.9 0.8

Proportion surviving

Surviving patients (%)

100

p=0.003

0.7 p=0.013

0.6 0.5

p=0.023

0.4 0.3 0.2

The first International consensus opinion for the definition of organ involvement and treatment response in immunoglobulin light chain amyloidosis was published in 2005 and has served the amyloid community well. 87 A revision is in progress, and the current status of hematologic and organ response are shown in Tables 4 and 5. Quantifying “response” in patients with AL is a major challenge. Since most patients have “low tumor burden,” with bone marrows and

143

0.1 0.0 0

aCR (65 patients, 2.5 deaths/100 py) VGPR (84 patients, 9.0 deaths/100 py) PR (67 patients, 14.7 deaths/100 py) NR (158 patients, 51.4 deaths/100 py)

12

24

36

48

Time (months)

B 1.0 0.9

Proportion surviving

0.8 p=0.014

0.7 0.6

p=0.008

0.5 0.4 0.3 0.2 0.1 0.0 0

NT-proBNP response (78 patients) NT-proBNP stable (56 patients) NT-proBNP progression (142 patients)

12

24

a 36

48

Time (months)

Fig. 6. Probability of survival depends on organ involvement at presentation: 474 patients seen between 1981 and 1992. Modified from: Kyle RA, Gertz M. Primary systemic amyloidosis: clinical and laboratory features in 474 cases. Seminars in Hematology. 1995;32:45–59.

Fig. 7. Validation of the criteria of response to treatment in AL amyloidosis. A. Survival of 374 patients based on hematologic response at 3 month after starting therapy. B. Survival of 276 patients with baseline serum N-Terminal-Pro B-Type Natriuretic Peptide (NT-proBNP) greater than or equal to 650 ng/L according to NT-proBNP response and progression at 3 months. Taken with permission from Palladini, G., A. Dispenzieri, et al. (in press). “Identification of the criteria for response to treatment in AL amyloidosis based on survival outcomes.” Journal of Clinical Oncology.

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Table 5 Defining amyloid organ involvement and response to therapy.a Involvementb

Improvement

Worsening

Kidney

24-hour urine protein > 0.5 g/day, predominantly albumin

50% increase in urinary protein loss (at least 1 g/24 h), or 25% worsening of creatinine or creatinine clearance

Heart

Echo: mean wall thickness > 12 mm, no other cardiac cause

Liver

Total liver span >15 cm in the absence of heart failure or alkaline phosphatase > 1.5 times institutional upper limit of normal Clinical symmetric lower extremity sensorimotor peripheral neuropathy Gastric-emptying disorder, pseudo-obstruction, voiding dysfunction not related to direct organ infiltration Direct biopsy verification with symptoms Direct biopsy verification with symptoms Interstitial radiographic pattern Tongue enlargement, clinical Arthropathy Claudication, presumed vascular amyloid Skin Myopathy by biopsy or pseudohypertrophy Lymph node (may be localized) Carpal tunnel

50% reduction in 24-hour urine protein excretion (at least 0.5 g/day) without worsening of creatinine or creatinine clearance by 25% over baseline New: NT-proBNP responsec (> 30% and >300 ng/L decrease in patients with baseline NT-proBNP ≥ 650 ng/L) Remaining Improvement by 2 NYHA classes without an increase in diuretic use or in wall thickness Removed 2011 ≥ 2 mm reduction in the interventricular septal (IVS) thickness by echocardiogram, or Improvement of ejection fraction by ≥20% ≥ 50% decrease in an initially elevated alkaline phosphatase level, or Decrease in liver size by at least 2 cm (radiographic determination). Improvement in electromyogram nerve conduction velocity (rare)

Nerve, peripheral Nerve, autonomic Gastrointestinal tract Lung Soft tissue

NYHA, New York Heart Association. a The final version of the latest International Consensus Response criteria have not been finalized. b Biopsy of affected organ or biopsy at an alternate site with clinical involvement. c Patients with progressively worsening renal function cannot be scored for NT-proBNP progression.

New: NT-proBNP progressionc (> 30% and >300 ng/L increase)a OR cTn progression (≥33% increase) Remaining Increase in NYHA class by 1 grade with a decreasing ejection fraction of ≥ 10%. Removed 2011 Increase in cardiac wall thickness by ≥2 mm (2-D ECHO) ≥50% increase of alkaline phosphatase above lowest level Not defined

Not defined

Not defined

Not defined Not defined

Not defined Not defined

Not defined

Not defined

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

Organ system

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

6.1. Hematologic response Hematologic response is important not only for “real time” assessment of the efficacy of therapy, but it is one of the most important prognostic determinants for both organ response and for overall survival. 93,94 When bone marrow biopsy, electrophoresis and immunofixation electrophoresis of the serum and urine were the only tools available for measurement of hematologic response, fewer than 50% of patients had “measurable” disease as defined by the multiple myeloma response criteria (i.e. serum M-protein greater than or equal to 1 g/dL or urine M-protein greater than 200 mg/24 h). Moreover, urine M-protein measurement is not reliable in a patient with nephrotic syndrome due to contamination with background non-specific proteinuria. Many patients were destined to have their hematologic “measurement” limited to a binary determination of positive or negative immunofixation studies. However, with introduction of the serum FLC measurement, nearly 75% of patients have measurable disease. 71,88,89 The International Response Consensus Criteria are in flux. 197 To date, four modifications have been made: First, a new criterion called very good partial response has been introduced, and it is defined as an involved serum immunoglobulin free light chain of less than 40 mg/L (Fig. 7A, Table 4). 95 A 90% reduction, consistent with the VGPR definition used in myeloma, was a serious contender for the definition, 96,97 but based on better performance characteristics of the 40 mg/L, the absolute value was chosen. Second, the definition of “measurable disease” was changed from an involved immunoglobulin free light chain of 100 mg/L to the difference of involved and uninvolved free light chains of 50 mg/L. 95 The third change in the criteria was the promotion of the serum immunoglobulin free light chain to primary importance 96 and demotion of serum protein electrophoresis derived M-protein to secondary status. 95 The final modification was the removal of the bone marrow requirement in the definition of amyloid complete response. 6.2. Organ response Improvement of organ function is clearly the most important end point for patients both in terms of quality of life and for overall survival. The internationally accepted organ response criteria for patients with AL amyloidosis are shown in Table 5 along with upcoming—but not finalized—revisions. 87,95,197 The major change relates to cardiac response criteria. The echocardiogram will no longer be required, and cardiac response and progression will be based on levels of NT-proBNP. 58,95 Patients will be assessable for cardiac response if their NT-proBNP is greater than or equal to 650 ng/L. A reduction of greater than 30% that is at least 300 ng/L qualifies as a response as does an improvement by 2 New York Heart Association classes without increase in diuretic use or in wall thickness. 98 The NT-proBNP response definition has been validated in a multi-institutional setting (Fig. 7B). 92,95 A potential concern with the NT-proBNP response is that lenalidomide treatment appears to be associated with NT-proBNP rises. 99–102 In the recent international collaborative report that validated NT-proBNP response, fewer than 5% of patients had lenalidomide based therapy. 95 The rationale for using the cardiac biomarkers in lieu of the echocardiogram for measuring response is that cardiac function in AL appears to rapidly improve when there is a reduction of the circulating amyloidogenic precursor, despite the amount of cardiac amyloid deposits remaining apparently unaltered, as measured by echocardiography. 58 There has also been interest in using troponin levels as markers of response. 95,99 Median time to organ response is 6–12 months, depending on the treatment. 78,93 The organ response criteria focus on renal, cardiac, and liver responses. Hematologic response precedes organ response (Figs. 1B and 8). Of those patients who achieve a complete hematologic response—be it through high dose chemotherapy

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with autologous peripheral blood stem cell transplantation (ASCT) or a simpler oral regimen like melphalan and dexamethasone— approximately 66 to 87% will achieve an organ response. 93,94 Of those who achieve a partial hematologic response, 30–56% will achieve an organ response. It is rare to have an organ response in the absence of a hematologic response, and in most series the most important time dependent prognostic factor is the ability to achieve response. Even when melphalan and prednisone chemotherapy was the only therapy available, those patients achieving organ response had a median survival of 89 months.78 Now that serum immunoglobulin free light chain response is an available measure, most trials are geared toward hematologic response for the following reasons: 1) free light chain responses are more rapid; 2) free light chain responses correlate highly with organ response; 3) free light chain responses are less subjective and more reproducible; and 4) free light chain responses have repeatedly been demonstrated to predict for overall survival.71,88,89,93,95–97,103 6.3. How deep a response is necessary The question of how much of a response is necessary is uncertain, there is no simple data driven answer given the narrow therapeutic window of therapy in patients with AL. Patients with deeper hematologic responses are more likely to have organ response and live longer; however, response in patients with organ impairment can become a significant cost. Patients not infrequently decompensate with the addition of immune modulator drugs (IMiDs). 99 Prolonged alkylator increases the risk for myelodysplastic syndrome. 104 Corticosteroids are fraught with their own toxicities and can also worsen existing congestive heart failure or edema. The most recent consensus is to aim for very good partial response or at least a 90% reduction in the involved free light chain if it can be achieved without putting the patient into too much jeopardy. Organ responses can occur with a hematologic partial response in as many as 30–56% of patients, and survival is markedly improved in patients achieving partial response as compared to no hematologic response even when corrected using landmark analysis. Whether long term outcomes will differ depending on the means of arriving at a partial or complete hematologic is unknown.105 This is most notable in the context of high dose chemotherapy with autologous stem cell transplant versus standard dose melphalan and dexamethasone. For patients achieving hematologic CR, the 5 year overall survival Transplantation No additional therapy

0

1

2

3

Years post transplantation Complete hematologic response documented at 3 months Fig. 8. Organ response follows hematologic response during observation period. This is a typical example of a patient achieving a complete hematologic response after an autologous stem cell transplantation at 3 months, and first sign of organ response not seen until 1 year after therapy and complete organ response not occurring until 3 years after therapy.

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is about 70% regardless of the treatment modality used to arrive at hematologic CR. 103,106,107 For patients undergoing ASCT and achieving CR, 10 year survival rates approach 60%.106 The biggest body of literature on adjuvant/consolidative chemotherapy in AL comes from Memorial Sloan Kettering. Two phase 2 studies have been done in which patients not achieving CR receive adjuvant thalidomide ± dexamethasone108 or bortezomib ± dexamethasone. 109 In the former study, thirty-one patients began adjuvant therapy, with 52% completing 9 months of treatment, and 42% achieving a deeper hematological response. By intention-to-treat, overall hematological response rate was 71% (36% complete response) with 44% having organ responses.108 In the latter study, 17 of 23 patients undergoing transplantation received adjuvant bortezomib and dexamethasone; 74% achieved a CR, and 58% had organ responses.109 7. Treatment At present, all treatments are directed at destroying the underlying plasma cell clone, which in turn reduces or eliminates the amyloidogenic clonal immunoglobulin light chain. It had been assumed that the amyloid fibrils detected in tissue biopsies were the source of tissue injury and dysfunction and that chemotherapy produced improvement in organ function by shifting the equilibrium from fibril formation to fibril dissolution. That hypothesis has been challenged with the hypothesis that the clonal amyloidogenic light chains form toxic intermediates responsible for the tissue damage. 110 In every day clinical practice, this debate is less important since there are currently no approved drugs that directly attack and/or dissolve the amyloid. The approach of using molecules and/or antibodies directed against serum amyloid protein or antibodies directed at the tertiary structure of the amyloid may be treatments of the future. 111–113 Other characteristics of these plasma cells that may eventually be targeted include CD20, which is expressed in approximately 40% of cases, 114 CD32, which is the low-affinity IgG Fc receptor, 115 and calretictulin, 116 which is a pleiotropic calciumbinding protein. Other potential therapies could include small interfering RNA molecules to inhibit pathologic immunoglobulin free light chain production.117 Nearly all cases of systemic AL will require therapy. Determining the extent of organ involvement helps estimate the risk associated with different treatment options. Which parameters will be followed

to modulate on-going treatment decisions should also be defined. This last recommendation cannot be overemphasized; patients with AL are complex, often very ill, and have multiple disease parameters to follow, making it difficult to track a patient's progress in a busy clinical practice. Treatment assessment focuses on 3 parameters (Fig. 1): 1) toxicity monitoring/management; 2) hematologic response; and 3) organ response. The goal in these patients is to achieve a reduction or disappearance of the precursor protein (clonal immunoglobulin free light chain), which can potentially halt the progression of organ damage and to allow for significant improvement of organ function (Table 5). 103 Fig. 9 illustrates the current treatment strategy employed for patients with systemic AL seen at the Mayo Clinic. Given the paucity of randomized trials and the heterogeneity of the disease, providing evidence based recommendations is a challenge. Simply stated, the two standards best studied to date are melphalan plus dexamethasone and high-dose melphalan with autologous stem cell transplantation. As will be discussed the experience with immune modulator drugs and proteasome inhibitors is relatively scanty. 7.1. Standard chemotherapy The successful use of cytotoxic chemotherapy to produce regression of AL was reported nearly 40 years ago, 118–120 and its value was verified in a double blinded prospective randomized study of melphalan and prednisone versus placebo in 1978. 121 Melphalan and prednisone doubled the overall survival as compared to colchicine in two subsequent randomized trials, making it the standard therapy for most patients with AL until the mid2000s. 91,122 The median time to response was 1 year. Although only 18% of patients responded to melphalan and prednisone, responders enjoyed a median survival of 89 months, whereas nonresponders had a median survival of 15 months. Nephrotic only patients with a normal serum creatinine enjoyed an organ response rate of 39%; whereas, patients with cardiomyopathy had organ response rates of only 15%. 78 Other treatments including single agent dexamethasone and VAD (vincristine, adriamycin, and dexamethasone) may produce responses in patients (Table 6). 88,123–130 Multi-agent alkylator based therapy did not improve overall survival, 131 but replacing the prednisone with dexamethasone resulted in higher response rates and better overall survival. 93 In 2004, Palladini et al. reported their experience treating 41 patients

Newly Diagnosed AL Transplant Eligible*

Transplant Ineligible

Not desiring SCT

Mel-Dex

High Risk†

Std. Risk

≥50% reduction in dFLC @ 6 wks and ≥ 90% reduction in dFLC @ 3 mos.

Yes

Obs.

No

Bortezomibbased Rx

≥ 50% reduction in dFLC @ 3 mos and ≥ 90% reduction in dFLC @ 6 mos.

Yes

Obs.

No

Bortezomibbased Rx

SCT with Mel 200

<90% reduction in dFLC @ day +100

High Risk†

≥90% reduction in dFLC @ day +100

Std. Risk

<50% reduction ≥50% reduction in dFLC in dFLC Bortezomib-based Rx

Obs.

Obs.

Fig. 9. Mayo Clinic off study AL treatment algorithm. Clinical trials are the preferred means of treating patients, but in the absence of a clinical trial, the Mayo Clinic algorithm is as above. The option for collecting and storing hematopoietic stem cells exists for a select group of patients. Selected patients may become eligible for PBSCT with cardiac and renal transplantation. dFLC = difference between involved and uninvolved serum free light chain levels. *To be transplant eligible, the following criteria should be met: “physiologic” age ≤ 70 years; performance score ≤ 2; troponin T b 0.06 ng/ml, creatinine clearance ≥ 30 ml/min (unless on chronic dialysis), NYHA class I/II, no more than 2 major organs significantly involved (liver, heart, kidney or autonomic nerve). †High Risk = Mayo Stage III (cTnT > 0.035 mcg/L and NT-proBNP > 332 ng/L).

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154 Table 6 Standard chemotherapy for AL.

MP91,120–122 VBMCP131 Melphalan IV (25 mg/m2 every 4–6 weeks)88 Dex123,124 Dex-IFN125 VAD88,126–130 Melphalan-Dexa93,105

N

Hematologic response, %

Organ response, %

Median survival, m

~ 200 49 20

28 29 50

20–30 31 …

18–29 29 ~ 50

77 93 ~ 100 96

… 33 42–50 52–67

15–35 … … 39–48

12–21 29 … 57–60

a Two other studies that included patients with very serve cardiac involvment had median OS rates of 10.5 to 17.5 months.53,123

who were not transplant candidates with melphalan and dexamethasone. Hematologic response rates of 67%, including 33% complete responses, and organ response rates of 48% were reported. 93 In a fiveyear update, these patients had an overall median survival of 5.1 years and progression-free survival of 3.8 years. 107 A total of 21 patients—13 nonresponders and 8 responders—died after a median of 1.6 years (range, 0.1–5.7 years). Death was not amyloid-related in 4 patients who responded to melphalan and dexamethasone, whereas it was due to progressive cardiac amyloidosis in the remaining cases. Two other phase 2 studies examining melphalan and dexamethasone had markedly inferior results with 3-month mortality rates of 23 and 28% and median overall survivals of 10.5 to 17.5 months. 59,132 These 2 series included patients with severely impaired cardiac function as assessed by soluble cardiac biomarkers demonstrating the relationship between patient selection and outcome. 133 The value of melphalan and dexamethasone was further validated in a prospective randomized study of 100 patients randomized to autologous stem cell transplant with high dose melphalan compared to oral melphalan and dexamethasone. 105 In this highly selected population, there was no difference between the two arms for hematologic responses, and the landmark analysis performed to correct for early mortality associated with transplant also showed no difference in overall survival. On an intention to treat basis, the median survival for melphalan and dexamethasone was 57 months versus 22 months for the stem cell transplant arm. This important study is limited by its small size for a disease that is as heterogeneous as AL. Among the 50 patients randomized to receive HSCT, only 37 actually received the planned transplant and 9 of those died within 100 days, a 24% treatment-related mortality, leaving only 28 patients for the landmark analysis. In contrast, of the 50 patients randomized to melphalan and dexamethasone, 43 patients received 3 or more cycles of therapy. The historical concern for myelodysplastic syndrome among AL patients receiving oral alkylator has been attenuated by more recent data demonstrating rates of myelodysplasia of 2.4% 93,107 rather than the historical rate of 7% of the total patient population, with a 42 month actuarial risk of myelodysplasia or acute leukemia of 21%. 134 This lower rate is attributed to the modest total dose of melphalan administered (median, 288 mg; range, 48–912 mg), even considering the additional cycles delivered in relapsing patients. 93,107

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greater than 0.06 ng/mL as an exclusion factor given a 28% 100 day all cause mortality among such patients in contrast to a 7% all cause mortality among those with a value below that threshold. 77 Capitalizing on the improved overall survival observed in patients with myeloma undergoing ASCT, ASCT has been widely applied to patients with AL, and over 1000 patients have been reported in the literature. The most commonly used conditioning regimen is melphalan 200 mg/m 2. Hematologic responses have been reported anywhere from 32% to 68% and complete hematologic responses from 16% to 50%. 80,90,94,105,136–138 Organ response is time dependent, and a median time to response can take up to one year. Organ response rates range anywhere from 31% to 64%. Patients with the deepest hematologic responses are more likely to have long term survival. 103,138 The treatment-related mortality is quoted from 6% to 27% at day 100 with the majority of deaths due to cardiac causes, but patients also succumb to multi-organ failure, hepatic insufficiency, hemorrhage and sepsis %. 80,90,94,105,136,137 At Mayo Clinic, the day-100 mortality is 7%, 139 and the median survival of patients with threeorgan involvement is 30 months, two-organ involvement 68 months, and 98 months for patients with one-organ involvement. 80 Overall survival of 337 patients is a projected median of 82 months. More recently, the Boston University group updated their transplantation results. Among 421 patients treated with HDM/SCT, the CR rate was 34%, the median event-free survival was 2.6 years, and the overall survival was 6.3 years. The seeming low event free survival was largely due to the poor outcomes of patients requiring attenuated doses of conditioning melphalan. This high risk group had a median EFS of 21 months in contrast to 43 months for those patients well enough to receive full dose melphalan. In a landmark analysis of patients surviving 1 year who achieved or did not achieve CR, respective overall survival rates were 13.2 years and 5.9 years with EFS of 8.3 and 2 years. 138 An alternative conditioning regimen incorporating bortezomib days −6, −3, + 1, and +4 has been explored in a pilot of 10 patients. 140 In this very fit population, the combination was well tolerated without any deaths during the 23 month follow-up. Response rates were encouraging with hematologic complete responses in 67% of patients. Often the question arises whether patients should receive induction therapy before moving to ASCT. Only one small randomized trial addressed this question. Patients were randomized to receive two cycles of oral melphalan and prednisone prior to transplant versus a direct transplant approach. There was no difference in overall survival between the two groups, and fewer patients in the pre-treatment group received a transplant. 141 Allogeneic hematopoietic stem cell transplantation is not a standard therapy for patients with AL. The European Group for Blood and Marrow Transplantation registry reported 19 patients with AL who underwent allogeneic (n = 15) or syngeneic (n = 4) hematopoietic stem cell transplantation between 1991 and 2003. 142 With a median follow-up time of 19 months, overall and progression-free survival rates were 60% and 53% at 1 year, respectively. Forty percent of patients died of transplant-related mortality. 7.3. Is high-dose chemotherapy with autologous stem cell transplantation the best therapy?

7.2. High-dose chemotherapy with stem cell transplant In routine practice, the first question asked is whether a patient is a candidate for high-dose chemotherapy with autologous peripheral blood stem cell support (ASCT) not because it is the best therapy, but because it is the therapy that is most restrictive and that requires the most planning. Risk factors for ASCT related mortality include physiologic age, performance status, cardiac function as determined by serum troponin T and functional class, uric acid, and number of organs involved. 53,54,77,80,135 In our practice, we use a troponin T of

Many will ask whether ASCT is the best therapy for patients with AL. Our opinion is that among those young patients with good risk disease, ASCT is an excellent option with potential for long event free survivals. There is, however, no randomized trial data support that it is superior therapy. 105 If done at institutions with low treatment related mortality, long term event free survival appears to be unsurpassed. 80,138,143 These excellent outcomes are somewhat confounded by selection bias, but there was a case controlled study performed that suggested that it was the better option, making ASCT

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an option worthy of discussion. 143 In contrast, for those patients who have significant comorbidity related to their AL meriting consideration of reduction of conditioning melphalan dose intensity, based on data from the randomized control trial and single arm outcomes from both Mayo Clinic and Boston University, transplant is likely not a preferred option. 103,105,138 7.4. Novel therapies for AL New therapies for amyloidosis involving incorporation of novel agents have also been described. Thalidomide, as a single agent, has a heightened toxicity in patients with amyloidosis and no hematologic or organ responses have been reported (Table 7). 144,145 In contrast, in combination with dexamethasone, 48% of 31 patients achieved hematologic response, with 8 (26%) organ responses. Median time to response was 3.6 months (range, 2.5–8.0 months). Treatmentrelated toxicity was frequent (65%), and symptomatic bradycardia was a common (26%) adverse reaction. 146 Wechalekar and colleagues treated 75 patients with a cyclophosphamide, thalidomide, dexamethasone combination. 147 A hematological response occurred in 74% of 65 evaluable patients including complete hematological responses in 21%. With a median follow-up of 22 months, median estimated overall survival from commencement of treatment was 41 months. Toxicity was not adequately assessed because this was not a clinical trial and further study of this combination has shown it to be less well tolerated than previously thought. 148 Palladini et al. treated 22 patients with cardiac involvement with the combination of melphalan, thalidomide and dexamethasone. 149 Despite a hematologic response rate of 36%, only 20% of patients were alive at 1 year. As lenalidomide has been used to treat AL, serious cardiac and renal toxicity have been reported, making it imperative to consider drug toxicity rather than ‘disease progression’ if patients on lenalidomide deteriorate. 99–102,150 In a trial of 23 patients, one patient had a hematologic and organ response with lenalidomide alone. 151 Eleven additional patients received dexamethasone, and overall response rates of 12 patients who completed more than three cycles of therapy were 10/12 with 9/12 hematologic and 5/12 organ responses. Ten patients did not complete three cycles of therapy, and analysis demonstrated that the cardiac troponin T level was highly predictive of patients being able to complete protocol therapy. In a similar study, with more restrictive entry criteria, of 24 evaluable patients, the overall hematologic response rate was 67%, including a 29% hematologic complete response. 152 These data have been updated, including 69 patients. Sixteen percent of patients achieved

a CR, and time to progression among patients achieving CR was 50 months. 153 Of the 11 patients achieving CR, there was 1 death and an additional 4 patients progressed off therapy. Two remained on treatment, and 4 had continued CR off therapy with a median time off therapy of 24 months. Both of these trials, and other subsequent studies have demonstrated that the starting dose of lenalidomide should be no higher than 15 mg per day administered days 1–21 every 28 days. 151,152 Most recently, Palladini et al. have reported their experience using lenalidomide and dexamethasone in patients who had failed both melphalan and bortezomib. 100 In this heavily pretreated group, there was a 38% response rate with complete responses. Risk factors for poorer outcomes included a high troponin I and diagnosis duration of less than 18 months. Only 50% of patients were alive at one year. The combination of lenalidomide with alkylator has been reported in 3 clinical trials. The most promising was that of melphalan, lenalidomide, and dexamethasone which was employed in 26 newly diagnosed patients with AL. 154 The population was highly selected since enrollment required an ECOG performance status of 0 or 1. Fifty-eight percent of patients achieved a PR including 23% who achieved a CR. Results with cyclophosphamide, lenalidomide, and dexamethasone do not appear as favorable, but selection criteria for these studies were less restrictive.155,156 In these studies, hematologic response rates ranged from 40–60% with CR rates of only 5–6%. One year survivorship was less than 66–89%. The newest immune modulator drug, pomalidomide has been combined with dexamethasone, and produced a hematologic response rate of 41%, including a 43% hematologic response rate in IMiD refractory patients. 157 The one year overall and progression free survival were 77% and 59% respectively. Bortezomib appears to be a highly active treatment in patients with AL, but to date there is very limited safety data available. Initial reports of hematologic response rates using bortezomib alone or with dexamethasone as part of clinical practice were approximately 70% including 25% complete response and 30% organ responses. 92 These reports have been succeeded by a large phase I/II trial of single agent bortezomib that included patients with previously treated AL. 158,159 The CAN2007 trial by Reece et al. evaluated two schedules of therapy, that is the standard twice weekly (days 1, 4, 8, 11, every 21 days) and a once weekly (days 1, 8, 15, and 22 every 35 days) schedule. The maximum tolerated dose was not reached after treating 31 patients, so the phase 2 portion of the study commenced using 1.3 mg/m 2 twice weekly and 1.6 mg/m 2 weekly in an additional 39 patients. Patients were highly selected in that they were required to have a

Table 7 Immune modulatory derivatives and proteosome inhibitors in patients with AL. Regimen 144

Thal 200–800 mg Thal/Dex146 Thal 200–800 mg196 Thal 50–200 mg145 CTX/Thal/Dex147 Mel–Dex–thal149 Len ± Dex151 Len ± Dex152 Len ± Dex100 Mel–Len–Dex154 Cyclo–Len–Dex155 Cyclo–Len–Dex156 Pom–Dex157 Bortez ± Dex92 Bortez158,159 Mel–Bz–Dex160

N

No prior Rx, %

≥2 organs, %

Cardiac, %

Heme response (CR), %

Organ response, %

Grades 3–4 AE, %

Median f/u, mo

OS

16 31 12 18 65 22 22 34 24 26 20 35 29 94 52b 17

6 42 58 28 41 86 43 9 0 100 0 69 0 19 0

31 61 67 50 ≥50 NR 57 ≥32 NR 62 NR 28 NR NR >44

25 38 42 67 16 100 65 38 75 58 60 63 83 73 56

25 48 0 0 74 36 43 47 38 58 40 60 38 72 67 94

0 26 11 11 33 18 26 21 4 50 15 24 10 30 24c

50 65 58 75 32 27 83 >35 50 81 60 69 72 29 NR

NR 32 2a 6a 18 28 17 NR 23 19 NR 9 8 12 18, 10, 38 11

NR NR NR NR 2 years 77%% 1 year 20% 2 years 50% NR 1 year 50% 2 years 81% 1 year b 80% 1 year b 66% 1 year 77% 1 year 76% 1 year 90% NR

(21) (5) (5) (21) (0) (23) (5) (6) (0) (25) (29) (56)

Rx, treatment; AE, adverse events; Cardiac, cardiac involvement; Dex, dexamethasone; f/u, follow-up; mo, months; IFN, interferon; Thal, thalidomide; Len, lenalidomide. a Median time on treatment. b The18 patients receiving dose escalation doses are excluded. c The denominator (n = 62) for this calculation includes some of the 18 dose escalation patients since that group contained 5 of the 15 organ responses.

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

Karnofsky performance status of 70% or higher, a NYHA classification of I or II, a systolic blood pressure of 90 mm Hg or higher, no symptomatic orthostatic hypotension, no atrial fibrillation, as well as no grade 2 or 3 atrioventricular block or sustained or recurrent nonsustained ventricular tachycardia along with the other usual eligibility criteria. Hematologic response rates were comparable at 67% and 68%, respectively, and the CR rate appeared to favor the once weekly schedule with rates of 24% (twice weekly) and 37%(once weekly). Time to both first response and best response was slightly more rapid using the twice weekly schedule (0.7 and 1.2 months, respectively) than the once weekly schedule (2.1/3.2 months), but with both schedules hematologic resposnes were rapid. Organ responses occurred in 15 patients overall. Rates of grade 3 or greater toxicity were observed in 79% of the twice weekly group as compared to 50% in the once weekly group. One year PFS was 75% and 72%, respectively, and the one year overall survival was 84% and 94%, respectively. The most common AEs were gastrointestinal. Comparing toxicity with the twice weekly schedule to that of the once weekly schedule, orthostasis was more than 3-times as common, cardiac disorders nearly 5-times as common and thrombocytopenia was 4times more frequent. Early reports of combinations of alkylator and bortezomib also appear promising, but safety data are sparse. The combination of melphalan, dexamethasone and bortezomib has produced response rates of 94%, but follow-up is short and toxicity data are lacking. 160 Case series of cyclophosphamide, dexamethasone and bortezomib have also been published with response rates of 93%. 161 These regimens cannot be considered standard until more comprehensive safety data are published. 7.5. Adjunctive and supportive therapy for AL Supportive care for these patients can be challenging, but careful attention to these issues is imperative. The three systems that require the most care are cardiac, renal, and nervous system. There are special considerations among patients with cardiac amyloidosis. These patients typically have diastolic dysfunction, and management approaches for systolic dysfunction often worsen patients' clinical status. Beta-blockade may cause clinical decompensation and should be used with caution. Afterload reduction with angiotensin converting enzyme inhibitors and angiotensin receptor blockers also tends to adversely impact patients unless they are used for the specific indication of hypertension. Diuretics are the mainstay of care with the best results achieved with a combination of loop diuretics and spironolactone. Metolazone may be of use as may periodic thoracentesis. 162 Patients with cardiac amyloid are at risk for intracardiac thrombi 163,164; in one study 35% of patients with AL who had transesophageal echocardiograms had atrial thrombus, the majority of which were located in the right atrial appendage or left atrial appendage.164 Anticoagulation should be considered recognizing that gastrointestinal bleeding is a potential risk. For those patients with atrial fibrillation, rate control can be a challenge since beta-blockade and calcium channel blockers are often poorly tolerated. Digoxin is considered contraindicated in cardiac amyloidosis due to concerns regarding digoxin binding and an increased risk of toxicity, but digoxin is often preferable over calcium channel blockers and beta-blockers for rate control in atrial fibrillation. 165 Non-dihydropyridine calcium channel blockers should be avoided due to its associated bradycardia and negative inotropic effects. 166 In our experience amiodarone is best tolerated, and electrophysiological maneuvers including atrioventricular ablation with permanent pacing may also be an option. Patients with cardiac amyloidosis are susceptible to malignant rhythms including ventricular tachycardia, ventricular fibrillation, and pulseless electrical activity. 51,167 The role of implantable cardioverter-defibrillators is controversial in these patients, since

149

both successes and failures have been documented. 167–170 No formal recommendation about their use can be rendered. Among patients with renal involvement, which is nephrotic syndrome in the majority, the major problem is third spacing due to hypoalbuminemia. This may be further exacerbated by coexisting cardiomyopathy. Diuretics are the mainstay of therapy. It is not unusual for nephrologists to institute an angiotensin converting enzyme inhibitor based on their management of diabetic nephropathy. There are no data to support this intervention in AL, but as long as patients have high blood pressure and adequate cardiac function, this intervention is not unreasonable as long as patients tolerate the medication. Adequate suppression of the underlying clone is the most important maneuver to improve renal function. 97 In one series from Italy, 67% of patients who presented with renal involvement had developed ESRD by 5 years, with early deaths censored. 171 The most important prognostic determinant for overall survival among these patients was the presence or absence of cardiac involvement with respective 5-year OS rates of 47% and 60%. In a recent report from the National Amyloidosis Center in the United Kingdom, among 752 patients with AL involving the kidney with an eGFR greater than or equal to 15 mL/min at baseline, 13% experienced progression to ESRD at a median of 27 months. On multivariable analysis, risk factors for renal progression included low serum albumin, especially lower than 20 g/L, and the absence of a 90% reduction in involved serum immunoglobulin free light chain at 6 months. Median survival from dialysis dependence was 39 months. 97 Patients with on dialysis may struggle with hypotension which can be successfully managed with pre-dialysis midodrine. In an earlier study performed at the Mayo Clinic that involved 211 patients seen before 1990, 18% received dialysis at approximately 14 months and approximately one-third of the renal patients went on to dialysis; however, none of the patients presenting with a creatinine less than 2 g/dL and a 24 hour urinary protein less than 2 g progressed to dialysis. The median survival of those instituting dialysis was 8.3 months, with the majority (21/31) dying of extrarenal causes of amyloidosis. 172 Amyloidosis patients with neuropathy typically have small fiber involvement which can be treated symptomatically with amitriptyline, nortriptyline, gabapentin, pregabalin, or duloxetine. Topical preparations that include various combinations of lidocaine, ketamine, and/or amitriptyline may also provide relief. For patients with neuropathy due to carpal tunnel syndrome, carpal tunnel release or carpal tunnel braces are of benefit. The autonomic insufficiency can be very difficult to manage, especially among patients with severe nephrotic syndrome or severe cardiomyopathy. Fludrocortisone and salt tablets are only useful in a minority of these patients since it may aggravate congestive heart failure or peripheral edema. The alpha-1 receptor agonist midodrine or the anticholinergic pyridostigmine can improve neurogenic orthostatic hypotension 173 and metoclopramide, used in diabetic gastroparesis, can help with gastric emptying. 7.6. Organ transplantation Solid organ transplantation (Tx) is a controversial intervention among patients with AL. Because the disease is systemic and presumably incurable, there is concern that the amyloid will either reoccur in the transplanted organ or progress in another organ resulting in a poor outcome. As illustrated in Table 8 and below, the best outcomes have occurred in the setting of careful patient selection, excluding patients with clinically evident multi-organ involvement, and among those who received adjuvant chemotherapy to eradicate the clone either before or after the solid organ Tx. 7.6.1. Cardiac transplantation Even when patients are placed on a cardiac Tx list, only a minority actually survive to surgery. 174–176 In all series, long term survival for AL patients is inferior to that of patients undergoing cardiac Tx for other

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Table 8 Solid organ transplant in patients with AL. Reference

N

Organ

Overall survival

Registry of ISHT1990, 1991177,178 UK 2004174

10†

Heart

17⁎

Heart

14⁎

Heart

11

Heart

French registry 2008182 Heidelberg 2009183

8 12

Heart Heart

Spanish registry2009184

1 year 88% 4 year 38% 1 year 59% 5 year ~ 37% 1 year 86% 5 year 45% 1 year 82% 5 year 65% 1 year 89% 1 year 83% 3 year 83% 1 year 43% 5 year 16% 1 year 78% 5 year 56% Alive at 5.3, 5.4, and 6 years 1 year 95% 5 year 67% No renal graft failure at 4.8 years 1 year 84% 5 year 76%

UK 2010

179

Mayo 2008

175

13

Heart

176

9

Heart

Boston 2003187 UK 201097,179

3 22

Kidney‡ Kidney‡

Mayo 2011186

19

Kidney‡

Boston 2010

ISHT, International Society for Heart Transplant. ⁎Unclear how much overlap between these two groups. Interval for Dubrey series was 1982–2002 and for Sattianayagam series, interval was 1984–2004, but there was no reference of which patients had been previously reported. † At least 8 were AL; unclear what other 2 were. ‡ Six other renal series have been excluded since they were a mix of patient with AL and other types of amyloidosis.

causes. The initial reports from an international registry for heart Tx were quite favorable 177; however, with additional follow-up, enthusiasm waned with a 4 year survival rate of approximately 38%. 178 A potential explanation for the extremely poor outcomes was that all but one patient had multisystem involvement prior to the cardiac Tx. The reported experience from the UK included 31 cases from two publications, 174,179 however, it is unclear which cases are overlapping. In the earlier publication including 17 cases of AL, 15 died from 0 to 116 months after the heart Tx with a 1 year survival of 59%. The survival of those patients receiving adjuvant chemotherapy was superior to those who did not with respective 2-year overall survival rates of 71% and 50%. 174 The updated UK series, included 14 cases of cardiac Tx for AL, appeared to be improved with a 1 year OS of 85% and a 5 year OS of 45%. Eight of these patients received an ASCT after their cardiac Tx. 179 With a median follow-up of 95 months in 5 of these patients, only 2 had died related to clonal relapse with progressive organ dysfunction. 180 In a report of 69 cardiac transplants from the UNOS database for the indication of amyloidosis, the 1- and 5-year survival estimates were 75% and 54%. 181 The difficulty with this study is that there is no separation between AL amyloidosis and other types of amyloidosis, and outcomes differ between orthotopic heart recipients with AL versus other types of amyloidosis. 174 Reports from the US predominantly include a strategy of cardiac Tx followed by ASCT. 175,176 Of 20 cases, the 1- and 5-year OS rates ranged from 78 to 82% and 56–65, respectively. In these two series, there was a total of 3 ASCT treatment-related deaths, and delayed deaths were mostly due to recurrent multi-organ amyloidosis. ASCT is most commonly performed 6–8 months after cardiac Tx. Doses of melphalan conditioning ranged from 140 to 200 mg/m 2. A French study included 8 patients, all of whom had extracardiac amyloid involvement. Five of the patients received chemotherapy prior to heart Tx, and 4 received chemotherapy after cardiac transplantation. Six received melphalan and dexamethasone and 3 received ASCT. Median follow-up was only 27 months, and there were 2 deaths, one at 1.5 months and another at 50 months. 182

In the Heidelberg series, 19 patients were considered for cardiac Tx, but only 12 survived long enough to receive a heart. 183 The transplanted group had superior baseline cardiac parameters both lower troponin and NT-proBNP. Another interesting aspect of this series is that four of the patients received their heart more than a year into their diagnosis, with one getting a cardiac transplant approximately 5 years into his diagnosis. Four patients had their heart transplantation after achieving a hematologic complete response and 5 patients had an ASCT after their cardiac transplantation with only 1 achieving a complete hematologic response. The authors identified “DANGER,” which included diarrhea, autonomic nervous system abnormalities, nutritional status, gastrointestinal bleeding history, elimination (renal function), and respiratory tract abnormalities as risk factors for poor outcome. In contrast the Spanish experience with cardiac Tx for AL appeared less promising. 184 Thirteen patients had cardiac transplant between 1984 and 2008, and all but 4 had died. Three deaths occurred in the first month. Four patients died of progressive systemic amyloidosis. One patient died of graft rejection during SCT. In six patients ASCT was planned, but performed in only 3 due to either peri-operative complications (n = 2) or inability to collect stem cells (n = 1). Of the 4 survivors, 2 had ASCT, 1 did not, and SCT was planned in another. 184 There is one case of orthotopic cardiac transplant followed by allogeneic stem cell transplant.185 At 18 months, this patient was alive with excellent performance status, but was not in hematologic complete response and with recurrence of amyloid in the myocardium. 7.6.2. Renal transplantation Most of the reports of renal Tx for amyloidosis combine AL with AA amyloidosis making outcomes for the former condition difficult to discern. The largest series are from the UK and the Mayo Clinic. 97,179,186 Among the 22 patients receiving a renal transplant over 25 years in the UK, there were no renal graft failures at 4.8 years and the 1- and 5-year overall survival rates were 95% and 67% respectively. Seventeen patients received chemotherapy without ASCT either before or after renal transplantation; 4 patients had ASCT prior to kidney transplantation. In the Mayo series, which included 19 patients with AL receiving renal transplantation over the course of 10 years, all but one had a living related donor. 183 Eight patients had an ASCT prior to kidney transplant, 6 had ASCT after kidney transplantation, and 5 patients received another form of chemotherapy to kill the plasma cell clone. With a median follow-up of 41 months, the 1- and 5-year overall survival rates were 84% and 76%. There were no graft failures. Causes of death included pulmonary embolism, post-transplant lymphoproliferative disorder, stroke, and a decision not to receive further care in the US. A small study from Boston University included 3 patients who had ASCT prior to kidney transplantation; patients are alive at 5.3, 5.4, and 6 years. 187 7.6.3. Liver transplantation Unlike hereditary amyloidosis, liver transplantation is rarely performed for patients with AL amyloidosis. 179,188 Outcomes are poor. In the UK series of 9 patients, the 1- and 5-year overall survival rates were 32% and 22%, respectively. Four had extrahepatic involvement at the time of transplantation. Six of the seven patients who died did so within 1 year of liver transplantation. Two of the 3 patients who received ASCT survived. In another case report, one year after liver transplantation, the recipient of OLT was alive and well, but with recurrent AL in the graft. 188 7.7. Treating localized amyloidosis The location of the amyloid is an important clue in recognizing the amyloid as being localized. The most frequent sites of localized amyloid are respiratory tract, genitourinary tract, and skin. 33 Pulmonary amyloid can be subdivided into nodular, laryngeal/

A. Dispenzieri et al. / Blood Reviews 26 (2012) 137–154

tracheobronchial, or diffuse interstitial. Only the third represents a manifestation of systemic AL. 189,190 The nodular form of amyloid presents as solitary pulmonary nodules or multiple nodules. This does not represent the systemic form of AL. 191 These nodules are not calcified and often require resection to exclude a diagnosis of malignancy. The usual treatment for tracheobronchial AL is yttrium– aluminum–garnet (YAG) laser resection of the tissue and more recently external beam radiation therapy. 192 Obstructive ureterovesicular amyloidosis is always localized. Patients present with hematuria or obstruction. 193 Surgery 194 and dimethylsulfoxide instillation 195 are the standard approaches. 8. Practice points • Consider the diagnosis with systemic symptoms and a monoclonal protein • Confirm diagnosis is AL and not another form of amyloidosis by using mass spectrometry of the amyloid biopsy specimen • Fully appreciate extent of disease, making sure that baseline cardiac biomarkers and serum immunoglobulin free light chains are completed • Optimize supportive management • Treat patients on clinical trials whenever possible • Do not reflexively apply multiple myeloma regimens to AL patients since toxicity profile is always greater in AL patients • Consider possibility that clinical deterioration is therapy related rather than disease related • Follow for both hematologic and organ response 9. Research agenda • Early detection of disease • Improvement of outcomes for patients with severe cardiac involvement • Maximizing risk stratified therapy approaches • Unraveling the genomic and proteomic drivers of disease • Development of fibril directed therapies Conflict of interest statement A.D. receives research funding from Celgene and Millenium and honoraria from Binding Site. M.A.G. receives honoraria from Celgene and Millennium, and is a member of an entity’s Board of Directors or advisory committees for Millennium. FB has no conflict. Acknowledgments Financial support: This work was supported in part by the The JABBS Foundation and The Predolin Foundation. AD is supported in part by grants CA125614, and CA107476 from the National Cancer Institute. References [1] Kyle RA, Linos A, Beard CM, et al. Incidence and natural history of primary systemic amyloidosis in Olmsted County, Minnesota, 1950 through 1989. Blood 1992;79(7):1817–22. [2] Sipe JD, Benson MD, Buxbaum JN, et al. Amyloid fibril protein nomenclature: 2010 recommendations from the nomenclature committee of the International Society of Amyloidosis. Amyloid 2010;17(3–4):101–4 Prepublished on 2010/11/03 as DOI 10.3109/13506129.2010.526812. [3] Vrana JA, Gamez JD, Madden BJ, Theis JD, Bergen 3rd HR, Dogan A. Classification of amyloidosis by laser microdissection and mass spectrometry based proteomic analysis in clinical biopsy specimens. Blood 2009;114:4957–9. [4] Desikan KR, Dhodapkar MV, Hough A, et al. Incidence and impact of light chain associated (AL) amyloidosis on the prognosis of patients with multiple myeloma treated with autologous transplantation. Leuk Lymphoma 1997;27(3–4):315–9.

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