Waldenström's macroglobulinemia

Waldenström's macroglobulinemia
Classification and external resources
Specialty Hematology and oncology
ICD-10 C88.0
ICD-9-CM 273.3
ICD-O M9761/3
OMIM 153600
DiseasesDB 14030
MedlinePlus 000588
eMedicine med/2395
MeSH D008258

Waldenström's macroglobulinemia (WM, also known as lymphoplasmacytic lymphoma) is cancer affecting B cells, a type of white blood cell. The main attributing antibody is immunoglobulin M (IgM). WM is an "indolent lymphoma," (i.e., one that tends to grow and spread slowly). It is a type of lymphoproliferative disease, which shares clinical characteristics with the indolent non-Hodgkin lymphomas.[1]

The disease, named after the Swedish oncologist Jan G. Waldenström, was first identified in 1944. As with other lymphomas, the disease is characterized by an uncontrolled increase of B-cells, i.e., white blood cells formed in the bone marrow and lymph nodes. The proliferation of B-cells interferes with the production of red blood cells, resulting in anemia. A unique characteristic of the disease is that the B-cells produce excess amounts of immunoglobulin protein (IgM), thickening the blood, and requiring additional treatment. WM is a rare disease, with only about 1,500 cases per year in the U.S. 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.[2]

History and classification

WM was first described by Jan G. Waldenström (1906–1996) in 1944 in two patients with bleeding from the nose and mouth, anemia, decreased levels of fibrinogen in the blood (hypofibrinogenemia), swollen lymph nodes, neoplastic plasma cells in bone marrow, and increased viscosity of the blood due to increased levels of a class of heavy proteins called macroglobulins.[3]

For a time, WM was considered to be related to multiple myeloma due to 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 WM under the category of lymphoplasmacytic lymphomas, itself a subcategory of the indolent (low-grade) non-Hodgkin lymphomas.[4] In recent years, there have been significant advances in the understanding and treatment of WM.[5]

Signs and symptoms

Signs and symptoms of WM include weakness, fatigue, weight loss and chronic oozing of blood from the nose and gums.[6] Peripheral neuropathy can occur in 10% of patients. Lymphadenopathy, enlargement of the spleen, and/or liver are present in 30–40% of cases.[7] Other possible signs and symptoms include blurring or loss of vision, headache, and (rarely) stroke or coma.

Causes

Waldenström's macroglobulinemia is characterized by an uncontrolled clonal proliferation of terminally differentiated B lymphocytes. The most common causes are a somatic mutation in MYD88 (90% of patients) and a somatic mutation in CXCR4 (27% of patients).[8] There has been an association demonstrated with the locus 6p21.3 on chromosome 6.[9] There is a 2- to 3-fold risk increase of developing WM in people with a personal history of autoimmune diseases with autoantibodies and particularly elevated risks associated with liver inflammation, human immunodeficiency virus, and rickettsiosis.[10]

There are genetic factors, with first-degree relatives shown to have a highly increased risk of also contracting Waldenström's.[11] There is also evidence to suggest that environmental factors including exposure to farming, pesticides, wood dust, and organic solvents may influence the development of Waldenström's.[12]

Genetics

Although believed to be a sporadic disease, studies have shown increased susceptibility within families, indicating a genetic component.[13][14] A mutation in gene MYD88 has been found to occur frequently in patients.[15] WM cells show only minimal changes in cytogenetic and gene expression studies. Their miRNA signature however differs from their normal counterpart. It is therefore believed that epigenetic modifications play a crucial role in the disease.[16]

Comparative genomic hybridization identified the following chromosomal abnormalities: deletions of 6q23 and 13q14, and gains of 3q13-q28, 6p and 18q.[17] FGFR3 is overexpressed.[18] The following signalling pathways have been implicated:

The protein Src tyrosine kinase is overexpressed in Waldenström macroglobulinemia cells compared with control B cells.[28] Inhibition of Src arrests the cell cycle at phase G1 and has little effect on the survival of WM or normal cells.

MicroRNAs involved in Waldenström's:[29][30]

MicroRNA-155 regulates the proliferation and growth of WM cells in vitro and in vivo, by inhibiting MAPK/ERK, PI3/AKT, and NF-κB pathways.

In WM-cells, histone deacetylases and histone-modifying genes are de-regulated.[38]

Bone marrow tumour cells express the following antigen targets CD20 (98.3%), CD22 (88.3%), CD40 (83.3%), CD52 (77.4%), IgM (83.3%), MUC1 core protein (57.8%), and 1D10 (50%).[39]

Pathophysiology

Symptoms include blurring or loss of vision, headache, and (rarely) stroke or coma are due to the effects of the IgM paraprotein, which may cause autoimmune phenomenon or cryoglobulinemia. Other symptoms of WM are due to the hyperviscosity syndrome, which is present in 6-20% of patients.[40][41][42][43] This is attributed to the IgM monoclonal protein 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.[44]

Diagnosis

A diagnosis of Waldenström's macroglobulinemia depends on a significant monoclonal IgM spike evident in blood tests and malignant cells consistent with the disease in bone marrow biopsy samples.[45] Blood tests show the level of IgM in the blood and the presence of proteins, or tumor markers, that are the key symptoms of WM. A bone marrow biopsy provides a sample of bone marrow, usually from the back of the pelvis bone. The sample is extracted through a needle and examined under a microscope. A pathologist identifies the particular lymphocytes that indicate WM. Flow cytometry may be used to examine markers on the cell surface or inside the lymphocytes.[46]

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 WM and multiple myeloma.[46] Anemia is typically found in 80% of patients with WM. 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 WM.[45]

Chemistry tests include lactate dehydrogenase (LDH) levels, uric acid levels, erythrocyte sedimentation rate (ESR), kidney and liver function, total protein levels, and an albumin-to-globulin ratio. The ESR and uric acid level may be elevated. Creatinine is occasionally elevated and electrolytes are occasionally abnormal. A high blood calcium level is noted in approximately 4% of patients. The LDH level is frequently elevated, indicating the extent of Waldenström macroglobulinemia–related tissue involvement. Rheumatoid factor, cryoglobulins, direct antiglobulin test and cold agglutinin titre results can be positive. Beta-2 microglobulin and C-reactive protein test results are not specific for Waldenström macroglobulinemia. Beta-2 microglobulin is elevated in proportion to tumor mass. Coagulation abnormalities may be present. Prothrombin time, 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.

Criteria for diagnosis of Waldenstrom macroglobulinemia 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.[47]

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.[1] Currently, median survival is 6.5 years.[48] In rare instances, WM progresses to multiple myeloma.[49]

The International Prognostic Scoring System for Waldenström’s Macroglobulinemia (IPSSWM) is a predictive model to characterise long-term outcome.[50][51] According to the model, factors predicting survival (n.b. the study quoted conversely refers to them as "5 adverse covariates") are:

The risk categories are:

Five-year survival rates for these categories are 87%, 68% and 36%, respectively.[52]

The IPSSWM has been shown to be reliable.[53] It is also applicable to patients on a Rituximab-based treatment regimen.[52] An additional predictive factor is elevated serum lactate dehydrogenase (LDH).[54]

Treatment

There is no single accepted treatment for WM.[55] There is marked variation in clinical outcome due to gaps in knowledge of the disease's molecular basis. Objective response rates are high (>80%) but complete response rates are low (0–15%).[5] Recently Yang et al. showed that the MYD88 L265P mutation induced activation of Bruton's tyrosine kinase, the target of the drug ibrutinib. Among 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 (Treon et al., New England Journal of Medicine 2015). Based on this study, the FDA approved ibrutinib for use in WM in 2015.[56]

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

WM patients are at higher risk of developing second cancers than the general population, however 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.[60] Waldenström himself stated "let well do" referring to watch and wait for patients who can simply be monitored without treatment. But on occasion the disease can be fatal, as it was to the French president Georges Pompidou, who died in office in 1974. The Shah of Iran also suffered from Waldenstrom's Macroglobulinemia which resulted in his ill fated trip to the US for therapy in 1979, leading to the takeover of the US Embassy in Tehran.[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 Macroglobulinemia agreed on criteria for the initiation of therapy. They recommended starting therapy in patients with constitutional symptoms such as recurrent fever, night sweats, 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.

Recently, autologous bone marrow transplantation has been added to the available treatment options.[66][67][68][69]

Salvage therapy

When primary or secondary resistance invariably develops, salvage therapy is considered. Allogeneic stem cell transplantation can induce durable remissions for heavily pre-treated patients.[70]

Drug pipeline

As of October 2010, there have been a total of 44 clinical trials on Waldenstrom's macroglobulinemia, excluding transplantion treatments. Of these, 11 were performed on previously untreated patients, 14 in patients with relapsed or refractory Waldenstrom's.[71] A database of clinical trials investigating Waldenström's macroglobulinemia is maintained by the National Institutes of Health in the US.[72]

Patient stratification

Patients with polymorphic variants (alleles) FCGR3A-48 and -158 were associated with improved categorical responses to Rituximab-based treatments.[73]

Epidemiology

Of all cancers involving the lymphocytes, 1% of cases are WM.[74]

WM is a rare disorder, with fewer than 1,500 cases occurring in the United States annually.[1] The median age of onset of WM is between 60 and 65 years, with some cases occurring in late teens.[1][7]

Research

One recent investigation showed that a population of cells, lacking both B-cell and plasma cell markers, has characteristics of cancer-initiating cells in Waldenstrom macroglobulinemia.[75]

See also

References

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  2. ↑ International Waldenstrom's Macroglobulinemia Foundation (IWMF). "Living with Waldenstrom's Macroglobulinemia."
  3. ↑ Waldenstrom J (1944). "Incipient myelomatosis or "essential" hyperglobulinemia with fibrinognenopenia-a new syndrome?". Acta Med Scand 117 (3–4): 216–247. doi:10.1111/j.0954-6820.1944.tb03955.x.
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  6. ↑ Kyle RA (1998). "Chapter 94: Multiple Myeloma and the Dysproteinemias". In Stein JH. Internal Medicine (5th ed.). New York: C.V.Mosby. ISBN 0-8151-8698-3.
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  8. ↑ Hunter, Z. R.; Xu, L.; Yang, G.; Zhou, Y.; Liu, X.; Cao, Y.; Manning, R. J.; Tripsas, C.; Patterson, C. J.; Sheehy, P.; Treon, S. P. (2013). "The genomic landscape of Waldenstrom macroglobulinemia is characterized by highly recurring MYD88 and WHIM-like CXCR4 mutations, and small somatic deletions associated with B-cell lymphomagenesis". Blood 123 (11): 1637–46. doi:10.1182/blood-2013-09-525808. PMID 24366360.
  9. ↑ Schop, Roelandt F.J.; Van Wier, Scott A.; Xu, Ruifang; et al. (2006). "6q deletion discriminates Waldenström macroglobulinemia from IgM monoclonal gammopathy of undetermined significance". Cancer Genet. Cytogenet. 169 (2): 150–3. doi:10.1016/j.cancergencyto.2006.04.009. PMID 16938573.
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  12. ↑ Royer, R.; Koshiol, J.; Giambarresi, T.; Vasquez, L.; Pfeiffer, R.; McMaster, M. (2010). "Differential characteristics of Waldenström macroglobulinemia according to patterns of familial aggregation". Blood 115 (22): 4464–4471. doi:10.1182/blood-2009-10-247973. PMC 2881498. PMID 20308603.
  13. ↑ McMaster, M. (2003). "Familial Waldenstrom's macroglobulinemia". Seminars in oncology 30 (2): 146–152. doi:10.1053/sonc.2003.50063. PMID 12720125.
  14. ↑ McMaster, M.; Goldin, L.; Bai, Y.; Ter-Minassian, M.; Boehringer, S.; Giambarresi, T.; Vasquez, L.; Tucker, M. (2006). "Genomewide linkage screen for Waldenstrom macroglobulinemia susceptibility loci in high-risk families". American Journal of Human Genetics 79 (4): 695–701. doi:10.1086/507687. PMC 1592553. PMID 16960805.
  15. ↑ Treon, S. P.; Xu, L.; Yang, G.; Zhou, Y.; Liu, X.; Cao, Y.; Sheehy, P.; Manning, R. J.; Patterson, C. J.; Tripsas, C.; Arcaini, L.; Pinkus, G. S.; Rodig, S. J.; Sohani, A. R.; Harris, N. L.; Laramie, J. M.; Skifter, D. A.; Lincoln, S. E.; Hunter, Z. R. (2012). "MYD88 L265P Somatic Mutation in Waldenström's Macroglobulinemia". New England Journal of Medicine 367 (9): 826–833. doi:10.1056/NEJMoa1200710. PMID 22931316.
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  44. ↑ Morbidity Mediated By The Effects Of IgM From Chapter 88 - Waldenström Macroglobulinemia/Lymphoplasmacytic Lymphoma. Hoffman, Ronald (2009). Hematology : basic principles and practic. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06715-0.
  45. 1 2 Waldenstrom Macroglobulinemia~workup at eMedicine
  46. 1 2 National Cancer Institute. Waldenström Macroglobulinemia: Questions and Answers. Retrieved on: 2011-08-14.
  47. ↑ Criteria for diagnosis of WM- IMWG 2009 guidelines
  48. ↑ Waldenstrom Macroglobulinemia at eMedicine
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