chronic leukemia lymphoma myeloma differentiated 14 September 1999 Pre- Transformed Ig Surface Surface Secreted Myeloma Major malignant counterpart

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Frank Fox
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1 Disease Usual phenotype acute leukemia precursor chronic leukemia lymphoma myeloma differentiated Pre- B-cell B-cell Transformed B-cell Plasma cell Ig Surface Surface Secreted Major malignant counterpart B- ALL CLL Macroglobulinemia Myeloma Major immunological abnormality Gamma globulins Monoclonal IgM Monoclonal Ig or light chain 1

Secreted Major malignant counterpart B- ALL CLL Macroglobulinemia Myeloma Major

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3 Chronic Lymphocytic Leukemia Most common leukemia Usual age > 50 yrs Increased proliferation and progressive p p g accumulation of neoplastic, immunologically incompetent, clonal lymphocytes B cell origin > 99% 3

progressive p p g accumulation of neoplastic,

4 Clinical Features of CLL Highly variable presentation Asymptomatic, or vague, non-specific complaints Recurrent infection 10% (often pneumococcus) Signs Lymphadenopathy (60%) Splenomegaly (50%) Hepatomegaly (< 40%) 4

Recurrent infection 10% (often pneumococcus) Signs

5 Clinical Features of CLL Laboratory blood and marrow lymphocytosis B cell monoclonality: κ vs λ surface light chain single Ig gene rearrangement hypoimmunoglobulinemia Prognosis Mean survival = months Range = few months to > 20 yrs 5

chain single Ig gene rearrangement hypoimmunoglobulinemia

6 Immunological Abnormalities in CLL Disturbed Ab production Hypogammaglobulinemia (50%) bacterial infection Monoclonal l Ig paraprotein in serum (10%) Autoantibodies (10%) Minor impairments in cell-mediated immunity Neoplastic lymphocytes Monoclonal surface Ig Abnormal response to Ig challenge Complications of CLL Recurrent tinfections Immune hemolysis Immune thrombocytopenia Progressive disease 6

cell-mediated immunity Neoplastic lymphocytes Monoclonal surface Ig Abnormal response to Ig

7 Rai Staging System for CLL Median survival Stage Features (years) I Lymphocytosis 13 II Lymphocytosis + lymphadenopathy 8 III Lymphocytosis y + splenomegaly 6 IV Lymphocytosis + anemia 1-2 V Lymphocytosis + thrombocytopenia 1-2 Treatment of CLL Stage 0 or 1 disease: No evidence that therapy prolongs survival Asymptomatic: watch and wait Symptomatic: Radiation for local complications Chemotherapy: fludarabine, alkylators, combinations Monoclonal antibodies (eg, Campath) Stem cell transplantation 7

0 or 1 disease: No evidence that therapy prolongs survival Asymptomatic: watch and wait Symptomatic: Radiation for local

8 Multiple Myeloma Clonal malignancy of plasma cells Increasing incidence Blacks:whites 2:1 Age range yrs (peak age 70 yrs) Cause unknown (Environmental/Genetic factors) 8

9 Classical Diagnostic Features of Myeloma Plasmacytosis in marrow Monoclonal protein in serum or urine Lytic disease of bone Marrow Plasmacytosis in Myeloma Plasma cells > 10% Usually much higher Often present in sheets Alternatively, biopsy-proven plasmacytoma Other causes of plasmacytosis: inflammation, cirrhosis, AIDS 9

Plasma cells > 10% Usually much higher Often present in sheets Alternatively,

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14 Diagnosis of Myeloma: Monoclonal Proteins 75-80% have serum monoclonal Ig (M-component, paraprotein, or spike on electrophoresis) 10-20% make light chains only rapid renal excretion no paraprotein on serum protein electrophoresis Non-secretory myeloma rare (< 1%) Other causes of monoclonal proteins (eg, CLL, lymphoma, benign monoclonal gammopathy) Apply serum or urine Protein Electrophoresis (PEP): proteins separated according to charge and size Stain Scan 14

electrophoresis Non-secretory myeloma rare (< 1%) Other causes of monoclonal proteins (eg, CLL, lymphoma, benign

15 Serum Protein Electrophoreses in 2 Patients with Myeloma #1 #2 15

16 Immunofixation Electropheresis 16

17 Bone Disease in Myeloma Unbalanced osteoclast activity Radiographic manifestations Osteoporosis almost invariable Usually multiple lytic lesions Axial skeleton involved (active marrow) Osteoblastic reaction minimal Hypercalciuria and hypercalcemia 17

Usually multiple lytic lesions Axial skeleton involved (active

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21 Benign Monoclonal Gammopathy Monoclonal Ig as isolated finding More common than myeloma No bone disease, anemia, renal dysfunction Most remain stable About 10% eventually develop classical myeloma 21

22 Myeloma at Presentation Early - asymptomatic, incidental diagnosis Paraprotein on electrophoresis Mild marrow plasmacytosis Solitary plasmacytoma (10% of cases) Late - symptomatic Bone pain (usually lower back) Pneumococcal infection Systemic symptoms (eg, weakness, weight loss) Related to anemia, renal failure, hypercalcemia Hyperviscosity Syndrome Due to aggregating paraprotein Pathogenesis Circulatory insufficiency, abnormal hemostasis Manifestations Bleeding Dyspnea (congestion on CXR) Encephalopathy and visual disturbances 22

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25 Immunological Features of Myeloma Monoclonal Ig and/or monoclonal light chain Levels of normal Ig s (hypogammaglobulinemia) Cellular immune responses usually preserved Bacterial infections common Early: S pneumoniae Late: S aureus, Gram negative rods Amyloidosis in Myeloma Due to light chain deposition in tissues Incidence: λ amyloid > κ amyloid Organs commonly involved: Skin Tongue and GI Heart Peripheral nerves Kidneys Soft tissues No effective therapy, except?stem cell transplant 25

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27 NEJM 2007; 356:

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29 Therapy for Myeloma Bisphosphonates (pamidronate, zoledronate) Radiotherapy Corticosteroids and conventional chemotherapy Thalidomide and lenalidomide (antiangiogenesis) Bortezomib (proteasome inhibitor) Stem cell transplantation 29

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FastTest. You ve read the book... ... now test yourself FastTest You ve read the book...... now test yourself To ensure you have learned the key points that will improve your patient care, read the authors questions below. Please refer back to relevant sections