Waldenström macroglobulinemia

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Waldenström's macroglobulinemia
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Waldenström macroglobulinemia
Other namesLymphoplasmacytic lymphoma
SpecialtyHematology and oncology

Waldenström macroglobulinemia (

isoforms.[5][6]

Waldenström macroglobulinemia is a rare disease, with only about 1,500 cases per year in the United States. It occurs more frequently in older adults.[7] While the disease is incurable, it is treatable. Because of its indolent nature, many patients are able to lead active lives, and when treatment is required, may experience years of symptom-free remission.[8]

Signs and symptoms

Signs and symptoms of Waldenström macroglobulinemia include

blood from the nose and gums.[9] Peripheral neuropathy occurs in 10% of patients. Enlargement of the lymph nodes, spleen, and/or liver are present in 30–40% of cases.[10] Other possible signs and symptoms include blurring or loss of vision, headache, and (rarely) stroke or coma.[citation needed
]

Causes

Waldenström macroglobulinemia is characterized by an uncontrolled clonal proliferation of terminally differentiated B lymphocytes. The most commonly associated mutations, based on whole-genome sequencing of 30 patients, are a

human immunodeficiency virus, and rickettsiosis.[14]

There are

environmental factors, including exposure to farming, pesticides, wood dust, and organic solvents, may influence the development of Waldenström macroglobulinemia.[16]

Genetics

Although believed to be a sporadic disease, studies have shown increased susceptibility within families, indicating a genetic component.

miRNA signature however differs from their normal counterpart. It is therefore believed that epigenetic modifications play a crucial role in the disease.[20]

signalling pathways
have been implicated:

The protein

Src tyrosine kinase is overexpressed in Waldenström macroglobulinemia cells compared with control B cells.[32] Inhibition of Src arrests the cell cycle
at phase G1 and has little effect on the survival of Waldenström macroglobulinemia or normal cells.

MicroRNAs involved in Waldenström:[33][34]

MicroRNA-155 regulates the proliferation and growth of Waldenström macroglobulinemia cells in vitro and in vivo, by inhibiting MAPK/ERK, PI3/AKT, and NF-κB pathways.[citation needed]

In Waldenström macroglobulinemia cells,

MUC1 core protein (57.8%), and 1D10 (50%).[43]

Pathophysiology

Symptoms including blurring or loss of vision, headache, and (rarely)

autoimmune phenomena or cryoglobulinemia. Other symptoms of Waldenström macroglobulinemia are due to hyperviscosity syndrome, which is present in 6–20% of patients.[44][45][46][47] This is attributed to the IgM monoclonal protein molecules increasing the viscosity of the blood by forming aggregates to each other, binding water through their carbohydrate component and by their interaction with blood cells.[48]

Diagnosis

A diagnosis of Waldenström macroglobulinemia depends on a significant monoclonal IgM spike evident in blood tests and

lymphocytes that indicate Waldenström macroglobulinemia. Flow cytometry may be used to examine markers on the cell surface or inside the lymphocytes.[50]

Additional tests such as

computed tomography (CT or CAT) scan may be used to evaluate the chest, abdomen, and pelvis, particularly swelling of the lymph nodes, liver, and spleen. A skeletal survey can help distinguish between Waldenström macroglobulinemia and multiple myeloma.[50] Anemia occurs in about 80% of patients with Waldenström macroglobulinemia. A low white blood cell count, and low platelet count in the blood may be observed. A low level of neutrophils (a specific type of white blood cell) may also be found in some individuals with Waldenström macroglobulinemia.[49]

Chemistry tests include

activated partial thromboplastin time, thrombin time, and fibrinogen tests should be performed. Platelet aggregation studies are optional. Serum protein electrophoresis results indicate evidence of a monoclonal spike but cannot establish the spike as IgM. An M component with beta-to-gamma mobility is highly suggestive of Waldenström macroglobulinemia. Immunoelectrophoresis and immunofixation studies help identify the type of immunoglobulin, the clonality of the light chain, and the monoclonality and quantitation of the paraprotein. High-resolution electrophoresis and serum and urine immunofixation are recommended to help identify and characterize the monoclonal IgM paraprotein. The light chain of the monoclonal protein is usually the kappa light chain. At times, patients with Waldenström macroglobulinemia may exhibit more than one M protein. Plasma viscosity must be measured. Results from characterization studies of urinary immunoglobulins indicate that light chains (Bence Jones protein), usually of the kappa type, are found in the urine. Urine collections should be concentrated. Bence Jones proteinuria is observed in approximately 40% of patients and exceeds 1 g/d in approximately 3% of patients. Patients with findings of peripheral neuropathy should have nerve conduction studies and antimyelin associated glycoprotein serology.[citation needed
]

Criteria for diagnosis of Waldenström macroglobulinemia include:

  1. IgM monoclonal gammopathy that excludes chronic lymphocytic leukemia and mantle cell lymphoma
  2. Evidence of anemia, constitutional symptoms, hyperviscosity, swollen lymph nodes, or enlargement of the liver and spleen that can be attributed to an underlying lymphoproliferative disorder.[51]

Treatment

There is no single accepted treatment for Waldenström macroglobulinemia.

response rates are high (> 80%) but complete response rates are low (0–15%).[53] The medication ibrutinib targets the MYD88 L265P mutation induced activation of Bruton's tyrosine kinase.[54] In a cohort study of previously treated patients, ibrutinib induced responses in 91% of patients, and at 2 years 69% of patients had no progression of disease and 95% were alive.[55] Based on this study, the Food and Drug Administration approved ibrutinib for use in Waldenström macroglobulinemia in 2015.[56]

There are different treatment flowcharts: Treon[57] and mSMART.[58][clarification needed]

Patients with Waldenström macroglobulinemia are at higher risk of developing second cancers than the general population, but it is not yet clear whether treatments are contributory.[59]

Watchful waiting

In the absence of symptoms, many clinicians will recommend simply monitoring the patient;

Mohammad Reza Shah Pahlavi, the Shah of Iran, also had Waldenström macroglobulinemia, which resulted in his ill-fated trip to the United States for therapy in 1979, leading to the Iran hostage crisis.[61]

First-line

Should treatment be started it should address both the paraprotein level and the lymphocytic B-cells.[62]

In 2002, a panel at the International Workshop on Waldenström's Macroglobulinemia agreed on criteria for the initiation of therapy. They recommended starting therapy in patients with constitutional symptoms such as recurrent

fatigue due to anemia, weight loss, progressive symptomatic lymphadenopathy or spleen enlargement, and anemia due to bone marrow infiltration. Complications such as hyperviscosity syndrome, symptomatic sensorimotor peripheral neuropathy, systemic amyloidosis, kidney failure, or symptomatic cryoglobulinemia were also suggested as indications for therapy.[63]

Treatment includes the monoclonal antibody rituximab, sometimes in combination with chemotherapeutic drugs such as chlorambucil, cyclophosphamide, or vincristine or with thalidomide.[64] Corticosteroids, such as prednisone, may also be used in combination. Plasmapheresis can be used to treat the hyperviscosity syndrome by removing the paraprotein from the blood, although it does not address the underlying disease.[65] Ibrutinib is another agent that has been approved for use in this condition. Combination treatment with ibrutinib and rituximab showed significantly higher disease progression free survival than with just rituximab treatment.[66]

Autologous

bone marrow transplantation is a treatment option.[67][68][69][70]

Zanubrutinib is indicated for the treatment of adults with Waldenström macroglobulinemia.[71]

Salvage therapy

When primary or secondary

Allogeneic stem cell transplantation can induce durable remissions for heavily pre-treated patients.[72]

Drug pipeline

As of October 2010, there have been a total of 44 clinical trials on Waldenström macroglobulinemia, excluding transplantation treatments. Of these, 11 were performed on previously untreated patients, 14 in patients with relapsed or refractory Waldenström.[73] A database of clinical trials investigating Waldenström macroglobulinemia is maintained by the National Institutes of Health in the US.[74]

Patient stratification

Patients with

alleles) FCGR3A-48 and -158 were associated with improved categorical responses to rituximab-based treatments.[75]

Prognosis

Current medical treatments result in survival of some longer than 10 years; in part this is because better diagnostic testing means early diagnosis and treatments. Older diagnosis and treatments resulted in published reports of median survival of approximately 5 years from time of diagnosis.[4] Currently, median survival is 6.5 years.[76] In rare instances, Waldenström macroglobulinemia progresses to multiple myeloma.[77]

The International Prognostic Scoring System for Waldenström's Macroglobulinemia is a predictive model to characterise long-term outcomes.[78][79] According to the model, factors predicting reduced survival[80] are:

  • Age > 65 years
  • Hemoglobin ≤ 11.5 g/dL
  • Platelet count ≤ 100×109/L
  • B2-microglobulin > 3 mg/L
  • Serum monoclonal protein concentration > 70 g/L

The risk categories are:

  • Low: ≤ 1 adverse variable except age
  • Intermediate: 2 adverse characteristics or age > 65 years
  • High: > 2 adverse characteristics

Five-year survival rates for these categories are 87%, 68% and 36%, respectively.[81] The corresponding median survival rates are 12, 8, and 3.5 years.[82]

The International Prognostic Scoring System for Waldenström's Macroglobulinemia has been shown to be reliable.[83] It is also applicable to patients on a rituximab-based treatment regimen.[81] An additional predictive factor is elevated serum lactate dehydrogenase (LDH).[84]

Epidemiology

Of cancers involving the lymphocytes, 1% of cases are Waldenström macroglobulinemia.[85] A rare disorder, there are fewer than 1,500 cases occurring in the United States annually.

The median age of onset is between 60 and 65 years, with some cases occurring in late teens. Notable victims of the disease include dancer/choreographer Gower Champion, who died of the disease in 1980, aged 61;[4][10] and former French President Georges Pompidou.

History

Waldenström macroglobulinemia was first described by

macroglobulins.[86]

For a time, Waldenström macroglobulinemia was considered to be related to multiple myeloma because of the presence of monoclonal gammopathy and infiltration of the bone marrow and other organs by plasmacytoid lymphocytes. The new World Health Organization (WHO) classification, however, places Waldenström macroglobulinemia under the category of lymphoplasmacytic lymphomas, itself a subcategory of the indolent (low-grade) non-Hodgkin lymphomas.[87] Since the 1990s, there have been significant advances in the understanding and treatment of Waldenström macroglobulinemia.[53]

See also

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