1. Waldenström´s makroglobulinemi
Eva Kimby M.D. Ph.D
Professor
Karolinska Institute
Center of Hematology Karolinska University Hospital
Stockholm, Sweden
Fortbildningsdagarna i hematologi
Linköping 2 oktober 2014

2. Disclosures Eva Kimby
Advisory board : Celgene, Pharmacyclics, Gilead, Jansen, Teva
Föreläsararvode: Roche, Mundipharma, Jansen
Forskningsstöd: Pfizer, Roche

3. Professor
Jan Waldenström
Acta Med Scand 1944

4. Incipient myelomatosis or essential hyperglobulinemia with
fibrinogenopenia
Oronasal bleeding
Lymphadenopathy/enlarged lymphnodes
Anemia and thrombocytopenia
Hyperviscosity
Elevated erythrocyte sedimentation rate (SR)
Lymphoid cells and mast-cells in bone marrow
Waldenström J. Acta Med Scand 1944

5. Sjukdomssymptom Anemi/trombocytopeni Lymfadenopati B-symptom
Relativ anemi (hög plasmavolum)
Lymfadenopati
B-symptom
Hyperviskositet
Kryoglobulinemi
Cold agglutinin disease (CAD)
Neuropati
Amyloidos

6. WM – diagnos kriterier InternationaI Workshop on WM
Athens 2002*
Paris 2004
Stockholm 2008
Venice 2010
Newport 2012
London 2014
*Owen RG, et al. Clinicopathological definition of WM Semin Oncol. 2003Athens 2002
Enl WHO-klassifikationen 2008:
“WM is a lymphoplasmacytic lymphoma”

7. WM – diagnos kriterier Benmärgsinfiltration
Små lymfoplasmacytiska lymfocyter
Intertrabekulär växt
Typisk immunfenotyp
Biopsi med immunfärgning (IHC)
Aspiration och flödescytometri

8. WM immunofenotyp Positivitet för Negativitet för
Light chain restricted IgM
CD19, CD22, (dim), CD25, CD27 och CD52
CD5 positivitet i 5-20% av fallen
Negativitet för
CD10, CD23, CD103 och CD138
En subklon, främst plasmaceller , är CD20-negativ och CD138-positiv
Paiva B, et al. Leukemia Jan;28(1):
Multiparameter flow cytometry for the identification of the WM's clone in
IgM-MGUS and WM: new criteria for differential diagnosis and risk stratification.

9. FISH: 6q deletion (gen: BLIMP-1)
-10% Konventionell cytogenetics
34% med FISH
May have prognostic significance
more aggressive clinical features

10. M-spike in serum required for WM
Irrespective of IgM concentration
Splenomegaly+IgM spike
MYD88 mutations status
till hjälp vid differentiering från
Marginal zons lymfom (7-10%)
IgM- myeloma
KLL med plasmacytisk differentiering (4%)
Differential diagnosis: Splenisk marginal zons lymfom
CD22+ and CD11c+

11. MYD88 L265P mutation in WM
Whole genome sequencing of lymphoplasmacytic cells
from 30 WM-pts (paired normal tissue sequencing in 10 pts)
A recurring sequence variant on chr 3p22.2 identified with a single nucleotide change in the myeloid differentiation primary response (MYD88) gene
Sanger sequencing confirmed the MYD88 L265P variant in tumor samples from 26 patients
Treon SP, Xu L, Yan G et al. NEJM. 2012;

12. Metod för MYD88 L265P Allele-specific PCR i blod:
Circulating WM-cells –
High concordance BM-blood
if CD19+ selected cells are used for allele-specific PCR
patient-friendly, but not specific

13. Diagnostic criteria (Mayo):
IgM MGUS
Asymtomatic WM
Symtomatic WM
M-component, type IgM
< 30g/L, and/or
≥30g/L, and/or
M-component, type IgM ≥30g/L, and/or
LPL in BM <10%
LPL in BM ≥10%
No WM related symtom*
No WM related symtom
WM relaterad symtom or end-organ -failure*
*B-symtom, anemia, hyperviscosity, lymphadenopathy/hepatosplenomegaly
MYD88 L265P vid IgM MGUS: 10-87%
Vid förekomst av mutation större risk för “malignant evolution”

14. C-X-C chemokine receptor typ 4 (CXCR4)
Somatisk ”WHIM-syndrome like” mutation av
CXCR4 hos 27% av WM patienter
Hunter Z et al, Blood 2014

15. C-X-C chemokine receptor type 4 (CXCR4)
Somatic ”WHIM-syndrome like” CXCR4 C1013G mutation: % of WM cases, thus not a diagnostic marker
The CXCR4 plays a role for cell trafficking of hematopoietic stem cells and also for clonal B-cells
CXCR4 WHIM mutation is related to high tumor proliferation and extramedullary dissemination and decreased survival in WM patients
A prognostic marker?

16. IgM-MGUS 15% to 20% of all MGUS
Distinct biological and clinical entity, different from IgG-IgA MGUS for nature and rate of progression:
Evolution into lymphoma (WM) or other related disorders
Higher risk of progression than IgG-IgA MGUS

17. MGUS: risk factors for evolution
Isotype
Risk Factors
Cesana, 2001
1,014
All
BM infiltration, BJ, High ESR,
Polyclonal Ig Reduction
Gregersen, 2001
1,247
BM infiltration, BJ, Polyclonal Ig Reduction, MC size
Kyle, 2003
213
IgM
MC Size, Serum Albumin
Rakjumar, 2005
1,384
Abnormal Free Light Chain Ratio, MC size, IgA-IgM isotype
Baldini, 2005
217
MC Size, Hemoglobin, Male sex

18. Asymptomatisk Waldenström:
Any size of serum IgM MC
Any degree of BM-LP infiltration at BM biopsy
No symptoms attributable to IgM MC/tumour infiltration
No evolution to overt LPD for at least 12 months from diagnosis

19. IgM-MGUS och A-WM Risk faktorer för evolution: Hb nivå och serum MC
Uppföljning:
Var 4-6 månad : Klinisk undersökning
Hb och serum Ig M
OBS! Tänk på sekundära problem; neuropati, amyloidos

20. Utredning vid misstänkt Waldenströms makroglobulinemi
• Blodstatus
• Elektrolytstatus + albumin + urat
• Leverstatus + LD
• Beta-2-mikroglobulin
• Serum protein elektrofores med immunfixation (termos)
• Hepatit C serologi
• Dygns samling av urin för protein elektrofores
Bildundersökning
Datotomografi hals, thorax, buk
Rtg pulm vid övre luftvägssymtom eller tidigare infektion
Histologisk undersökning
• Benmärgsbiopsi och aspiration (morfologi, immunfärgningar, flödesytometri)

21. Fler prover: DAT = direkt antiglobulin test
ev prov i termos för köldagglutininer
Kryoglobuliner (vid misstanke om kryoglobulinemi, prov i termos)
Serum viskositet (vid hyperviskositetsymtom eller hög M-komponent >40g/L)
P-FLC = fria lätta kedjor?

22. Symtom orsakade av M-komponent
Symtom orsakade av benmärgsinfiltration
Trötthet, yrsel pga anemi
Blödningar, hud, näsa, blåmärken pga trombocytopeni
Infektionskänslighet pga leukopeni och hypogammaglobulinemi
Symtom orsakade av M-komponent
Huvudvärk, synrubbningar, blödningar, dyspné,
pga hyperviskositet
Njursvikt, Raynaudfenomen, hudutslag, led- muskel-smärta,
neuropati (pga Kryoglobulinemi typ I och II)
Hemolytisk anemi pga autoantikroppar (I-antigen)
Trombocytopeni pga autoantikroppar
Perifer neuropati pga autoantikroppar
mot MAG (myelin-associerad glycoprotein) eller GM1 (ganglioside M1)

23. Andra symtom
• Lymfknuteförstoring
• Hepatosplenomegali
• Hud (bullösa hudutslag, papuler, Schnitzler syndrom)
• Gastrointestinala (diarré, malabsorbtion)
• Njurar (proteinuri, njursvikt)
• Trötthet, viktnedgång, macroglossia och dysfunktion av involverade organ
pga infiltration av amyloida fibriller
CNS påverkan (Bing-Neels syndrom)

24. När ska behandling inledas?
Serum IgM i sig är inte en behandlingsindikation
Watch and wait
Anaemia/trombocytopenia
Adenopati/organomegaly
Hyperviskositet
Kryoglobulinaemi
Köld agglutinin
Neuropati
Amyloidos
Transformation

25. The International prognostic Scoring System for WM (ISSWM)
Risk group
Adverse covariates*
5-year survival
Low
1 (except age)
87%
Intermediate
2 Or only age > 65 years
68%
High
> 2
36%
*Adverse covariates: IgM > 70 g/l Age > 65 years
β2M > 3mg/l
Hb ≤ 11.5 g/dl
Plts ≤ 100 x109/l
Morel P, et al. Blood 2009; 113:4163–4170 .

26. MYD88 L265P as a prognostic marker?
WM-cells harboring the L265P mutation, exhibit constitutive signaling leading to the hyperactivation of NF-κB
WM patients without the mutation have worse prognosis?
Level of mutation of importance?
Quantitative PCR?

27. Treatment options for WM
Single agents
Rituximab (standard or extended schedule)
Cladribine/fludarabine
Chlorambucil
Bortezomib
Rituximab-based combinations
R + fludarabine/cladribine/pentostatin +cyclophosphamide
R + bendamustine
R + cyclophosphamide + dexamethasone (DRC)
R+ bortezomib
Treatment recommendations by the 4th International Workshop on WM Dimopoulos MA, et al. J Clin Oncol 2009; 27:120–126
Updated at last International Workshop on WM, Newport 2012, in manuscript .

28. Single-agent therapy Single-agent rituximab Plasmapheresis
Low Ig M and cytopenias
Plasmapheresis
High Ig M - risk of “flare”
Single-agent chlorambucil
Old age and slow progression .

29. Plasmapheresis for removal of IgM
Hyperviscosity-related symptoms
Prevention
Reduce IgM before rituximab
Reversing (rapid effect needed)
Headache, breathlesness
Retinopathy
Venous dilatation
Bleeding
Anemia

30. One randomized trial: WM1 Final results ASH 2011
WM 1- prospective randomized trial
Previously untreated WM (339), MZL(37) and LPL
Median age: 68 years (40-89)
NCRI Lymphoma Clinical Studies Group (UK)
Groupe d’Etudes sur la Leucémie Lymphoïde Chronique et la maladie de Waldenström (France)
Leblond V et al. J Clin Oncol ;31(3):301-7. 30

31. WM 1- prospective randomized trial 07/01-12/09 (n=414)
Chlorambucil: 8 mg/m2 x10 days/28 days
(max 12 cycles)
CR+PR: 38.6%
Oral Fludara: 40 mg/m2 orally x5 days/28 days (max 6 cycles)
CR+PR: 47.8 %

32. WM1 progression-free survival20 40 60 80
100
0.0
0.2
0.4
0.6
0.8
1.0
Months
PFS
FAMP
CHB N
Median (Months)
Fludarabine
207
36.3
Chlorambucil
27.1
Factors influencing PFS
Negatively: Clb, albumin<35g/l, ptls<100, age>70y
P=0.01
Median follow up is 32.5 months. 32

33. Survival OS 5 years Chlorambucil: 61.4% [52.9;71.3]
Fludarabine: % [ ]
(p=0.04)

34. CD20 + tumor cells Rituximab of value?
The addition of R to front-line therapy with
CHOP in Lymphoplasmacytic lymphoma (including WM)
A higher response rate
Longer time to treatment failure
Buske C, et al. Leukemia. 2009;23:153-61

35. FC and FCR good efficacy
Fludarabine/combinations
FC and FCR good efficacy
Hematologic toxicities
Grade 3/4
Neutropenia
Thrombocytopenia
Infections
Transformation
MDS/AML
Purinanalogues
No indication in younger patients if autologous ASCT
is a later alternative

36. Other less toxic combinations
Dexamethasone + rituximab + cyclophosphamide (DRC)1
Cyclophosphamide+prednisone+rituximab (CP-R)2
Bendamustine + rituximab3
1. Dimopoulos MA, et al. J Clin Oncol 2007; 25:3344–3349.
2. Ioakomidis L et al, Clin Lymphoma Myeloma Mar;9(1):62-6
3. Rummel MJ. Lancet Apr 6;381(9873):

37. Dimopoulos et al. J Clin Oncol 2007; 25: 3344-9
DRC regimen (n=72)
CR = 7%
PR = 67%
MR = 9%
SD = 8%
PD = 8%
Dexamethasone 20 mg IV day 1
Rituximab 375 mg/m2 IV day 1
Cyclophosphamide 100 mg/m2 PO
BID days 1–5
courses repeated every 21 days X6
ORR = 83%
Median time to 50% IgM reduction: 4.1 mo (range 0.7–14)
IgM flare: 32% (>25% IgM increase in 11% of patients)
Dimopoulos et al. J Clin Oncol 2007; 25:

38. R-Benda vs R-CHOP: Progression free survival
Rummel MJ et al.: Blood : 168 (abs#405). Lancet Apr 6;381(9873): 2 2

39. Other drugs Proteosominhibitors = bortezomib
carfilzomib
Everolimus decrease in serum IgM level, but increase in BM involvement
Lenalidomide unclear anemia
Carfilzomib, Rituximab and Dexamethasone (CaRD)
Highly active neuropathy sparing approach for
proteasome-inhibitor based therapy in WM
Treon et al, ASH 2013 , abstract 757

40. Bortezomib Multicenter protocol (BDR)
Cycle 1 (21-days): bortezomib 1.3 mg/m2 on days 1, 4, 8, 11
Cycles 2-5 (35-days): bortezomib 1.6 mg/m2 d 1,8,15, 22
Rituximab 375 mg/m2 + Dexa 40 days 1, 8, 15, 22 (8 infusions R)
Bortezomib Multicenter protocol (BDR)
Reference CR PR MR SD PD
ORR
Dimopoulos et al Blood 2009; 114: 2886a 3%
52%
16%
13%
71%
Dimopoulos et al. *
Blood Nov 7;122(19):
58% +7% VGPR
17% 9%
11%
85%
* Progression-free survival: 42 months
Peripheral neuropathy in 46% (grade ≥3 in 7%)
8% discontinued bortezomib due to neuropathy .. 40

41. WM therapy Single-agent rituximab High Ig M ....risk of “flare” DRC
Low Ig M and cytopenias
DRC
Bortezomib
Plasmapheresis
High Ig M ....risk of “flare”
Single-agent chlorambucil
Old age and slow progression .

42. Proposed European trial:
DRC versus DRC+ bortezomib sc

43. Treon et al, ASH 2013, abstract 251
Bruton’s Tyrosine Kinase (BTK) Inhibitor Ibrutinib in patients with relapsed/refractory WM
MYD 88 L265P - trigger NFκB signaling by direct interaction with BTK in WM cells
Ibrutinib 420mg/dag under 2 år, eller tills progress eller toxicitet
Mutations MYD88 L265P hos 49/43 (93%) WHIM-like CXCR4 hos 10/40 (25%) MYD88
Treon et al, ASH 2013, abstract 251

44. Ibrutinib in relapsed/refractory WM
Response impacted by mutations in CXCR4
but not in MYD88
Major response rate:
77% for patients with wild-type CXCR4 vs
30% in those with WHIM-like CXCR4 mutations (p=0.018)
Decreases in serum IgM M-spike (p=0.012) and improvements in hemoglobin (p=0.058) greater in patients with wild-type CXCR4
Treon et al ASH 2013, abstract 251

45. PI3K inhibitors GS1101/idelalisib inhibits PI3K-delta
a role in lymphocyte activation and mast cell degranulation
Rituximab and alkylating agent-refractory iNHL
125 enrolled patients: 58% FL, 22% SLL, 12% MZL,
8% LPL/WM
Ajay Gopal et al ASH 2013,abstract 85

46. Gopal G, Salles G, et al 2013, abstract 85
PI3K-Delta Inhibitor Idelalisib in Patients With Double Refractory Indolent B-Cell Lymphoma
ORR: 57% , LPL/WM - ORR :80%
ORR consistent across all subgroups, regardless of number of prior regimens, refractoriness to bendamustine or tumor bulk
Short median FU 9.4 months
Gopal G, Salles G, et al 2013, abstract 85

47. Relapse-studier hos oss: Indolent lymphoma
Randomiserad, double-blind, placebo-controllerad Fas 3 Studier
Idelalisib i kombination med
Bendamustin och rituximab (BR) (Gilead Study 125)
eller med
Rituximab alone (Gilead Study 124)
Patienter som ej är aktuella för högdos kemoterapi/SCT

48. Timepoint for response evaluation is crucial
WM Consensus Panel :
Recommendations on
Response Criteria
Weber D et al. Semin Oncol. 2003;30:
Updates
Kimby E, et al. Clin Lymphoma Myeloma. 2006:6:380-3.
Owen RG, et al. Br J Haematol. 2013;160:171-6
Timepoint for response evaluation is crucial

49. Delayed response
Conversion from PR to CR PR CR

50. Moderna response kriterier
Allele specific PCR for MYD88 L265p in
CD19+ selected blood cells?
NO: Quicker and greater reduction of tumor-cells
in blood than in BM, why BM is required

51. Schnitzler Syndrom
Monoclonal IgM gammopathy without features of lymphoproliferative disease
~ Chronic Uticaria- vascular reaction of the upper dermis
(wheals, severe itching)
~Bone pain
~Intermittent fever
~Arthritis
~Enlarged lymph nodes
~Hepato/splenomegali
~Elevated ESR

52. Bing-Neel syndrome
1936 Jens Bing and Axel Neel reported the association hyperglobulinemia and CNS symptoms
paresthesia, headache, gaitproblems, paralysis
Brain infiltration: plasmacells and lymphocytes

53. Bing Neel syndrome Definition
Infiltration of malignant lymphoplasmacytoid/WM cells in the central nervous system.
Meninges
(dura & arachnoid)
Intracerebral tumour
Cerebrospinal fluid
Involved?

54. Neurologic symptoms in patients with the "Bing-Neel Syndrome"
Cases of hyperviscosity, malignant transformation, vasculitis, and ophthalmologic manifestations excluded
Diagnosis: CSF, imaging and histopathology:
(1) lymphoplasmacytoid/ic cells infiltrating the CNS
(2) a non-cellular form: IgM deposition

55. BNS diagnostic work up Eye examination; fundoscopy MRI brain and spine
With contrast enhancement studies
FLAIR / diffusion weighted images
CSF analysis
Cell count (lymphocytosis)
Morphology
Flow cytometry
MYD88, IgH rearrangement
Total protein
Protein electrophoresis and immunofixation
Biobanking (chemokines and interleukins)
Brain biopsy if possible
Novel diagnostic approaches in BNS
K. Ina Ly et al, IWWM 2010 proceedings

56. Bing-Neel syndrome (BNS) – Orbital involvement - case
Orbitopathy and optic neuropathy
Orbital biopsy, cerebrospinal fluid studies, and neuroimaging can confirm a diagnosis of BNS involving the orbital soft tissues, optic nerves, meninges, and cauda equina
Stacy RC, Jakobiec FA, Hochberg FH, Hochberg EP, Cestari DM.
J Neuroophthalmol Sep;30(3):255-9.

57. Hydrocephalus in BNS
Proliferation of a small clone of lymphoma cells in the subarachnoid room
might give problems with resorption of spinal fluid and a risk of development of normotensive hydrocephalus

58. CNS penetrating chemotherapy
Methotrexate
 3 g/m2
Cytarabine
Intermediate to high dosing  2 g/m2
High dose intensive schemes as used in CNS DLBCL
Purine analogues
Fludarabine
Cladribine
Pass blood brain barrier
Dose related neurotoxicity
6 cases reports described so far

59. Use of fludarabin in 4 BNS patients
Response
Hematological
3 CR, 1 PR
CNS (MRI/CSF)
All CR; normalisation MRI and CSF
Clinical
2 complete response, in 2 patients mild symptoms persisted (paresthesias, double vision)
Follow up (6 months – 9 years)
1 patient with 2 relapses, second relapse CNS only

60. Giampaolo Merlini gmerlini@unipv.it
8th International Workshop on
Waldenström’s Macroglobulinemia
August 14-16, 2014
London, United Kingdom
Diagnosis and workup of the patient with Ig M
monoconal gammopathy - amyloidosis
Giampaolo Merlini

61. AL amyloidosis associated with IgM monoclonal protein: a distinct clinical entity
 6% of AL amyloidosis
4% have AA amyloidosis

62. Survival of patients with IgM-related AL according
to NT-proBNP and albumin: a distinct staging system
Palladini & Merlini Clin Lymphoma Myeloma Leuk. 2013;13:244-6
Terrier et al, Medicine, 2008;87:99-109

63. Treatment and outcome of 263 patients with IgM-related AL amyloidosis
Impact of bortezomib based regime on overall survival *
Given the rapid activity in patients with non-IgM AL amyloidosis and in WM, bortezomib-based therapy could be used in carefully selected patients.
Dimopoulos et al, Blood Jul 15
Roussel et al, ASH 2012 Annual Meeting Abstract 4074
*Palladini et al, Clin Lymphoma Myeloma Leuk ;11:143-5.

64. Sammanfattning: Waldenström macroglobulinemia
Biologi: MYD88 och CXCR4-mutationer
Terapi:
Rituximab-baserade kombinationsbehandlingar
Bortezomib ger snabbt svar
New agents
BTK inhibitors, new proteasome inhibitors
PI3K inhibitors, Bcl-2 inhibitors, antibodies (PD-1, CD38, SLAMF-7)
Risk-benefit
ISSWM och CXCR4 för “risk-adapted” terapi

65. Tack till alla kollegor ansvariga för Svenska Nationella riktlinjer för behandling av Waldenströms makroglobulinemi
Lena Brandefors, Norra
Magnus Svensson, Uppsala-Örebro
Monica Sender, Västra
Elena Holm, Lund-Malmö
Lotfi Kourosh, Linköping
Magnus Björkholm, Elin Helgadottir, Sigurdur Kristinsson,
Eva Kimby, Stockholm