Transcript N Engl J Med 2007

SEMINAR
TOPIC-AMYLOIDOSIS
PRESENTER-VIKAS THAKRAN
PRECEPTOR-PROF. A.B.DEY
DR.ANANT MOHAN
•Introduction
•Classification
•Molecular Mechanisms
•Incidence
•Clinical Features
•Diagnosis
•Treatment
•Prognosis
Introduction
•
•
•
•
Word amyloid given by Rudolf Virchow in 1958
Misnomer as it means starch
Misfolding of extracellular protein
Characterized by extracellular deposition of
pathologic insoluble fibrillar proteins.
Classification
•
Classified on basis of
•
Acquired Vs hereditary
•
Systemic Vs localized
•
Type of protein
•
Amyloid deposit classified using the capital letter A as the
1st letter of designation followed by the protein without any
open space; e.g AL

Terms such as primary, secondary, senile, dialysis-associated,
and myeloma-associated have been abandoned in favor of the
etiologically based, chemical terminology.
Nomenclature Committee of the international society of Amyloidosis2001.
N Engl J Med 2003;349:583-96.
Structural component
• All amyloid contain serum amyloid P (SAP) and
glycosoaminoglycan
-Glycosoaminoglycan is the carbohydrate moiety .
– protects against proteolysis and stabilize the
structure.
– Large negative charge of GAG indicate an effect
on the folding precursor proteins to form fibril.
– SAP thoughts to protect amyloid protein against
proteolysis.
N Engl J Med 2003;349:583-96.
N Engl J Med 2003;349:583-96.
Molecular mechanisms
AL amyloidosis
Light chain
Heavy chain
Basic structure of Immunoglobulin
Molecular mechanisms
AL amyloidosis
• Amyloid deposits contain intact L chain or fragments or
both, unusually heavy chain
• The fragments always include the variable segment plus
a piece of constant segment.
• Most common AL precursor proteins are Light chains of
the lambda (l) class (l vs k > 2:1)
• V l 6 class are the most amyloidogenic.
• Among VK, the VK1 subgroup is more amyloidogenic.
Mechanism of tissue injury
• Deposition of large amounts of fibrillar material causing
organ dysfunction
• Interacting with local receptors
•
Cytotoxic :Oxidative stress
Destruction of cell membrane
Formation of pathological ion channel.
Activation of apoptotic pathway
•
Protofibrils more toxic than mature fibrils
Proc Natl Acad Sci U S A 1998;95:6448
J Mol Recognit 2000;13:198
Science 2000;300:486
Incidence: 5.1-12.8 (9) cases per million person-years
Courtesy: IRCH
N Engl J Med 2003;349:583-96.
ITALIAN AMYLOIDOSIS STUDY GROUP
Symptoms and physical findings in 445 AL patients
Symptoms/physical findings
Fatigue
Oedema
Weight loss
Hepatomegaly
Dyspnea
%
51
41
35
22
20
J Of Intern Med 2004:255:159
Incidence : Indian scenario
• Retrospective analysis of 19,075 necropsies and 1169
renal biopsies
•75 cases of renal amyloidosis
33-necropsies
•82.6% diagnosed as secondary amyloidosis
•10.66% diagnosed as primary amyloidosis
42-biopsies
Indian J Pathol Microbiol. 1996 Jul;39(3):179
Primary
Secondary
Plasma cell dyscrasias
Chronic inflammtory states
60% of systemic amyloid in
developed countries
Cardiac, pleural, skin,
neuropathy
85% systemic amyloid in
developing countries
Renal, hepatic
Immunofixation for light
chains , serum free Light
chain assay, κ/λ, Bone
Marrow
Immunofixation for
SAA,KMNO4 treatment
causes loss of affinity to
congo red
Monoclonal Ig serum/urine ;
negative SAA
Sustained Positive SAA
Renal amyloidosis
Indian scenario
•15000 patients studied in AIIMS OPD
•Nephrotic syndrome – seen in 15%
• Amyloidosis seen in 6.4%
• Tuberculosis cause in 50% cases.
J Assoc Physicians India. 2000 Jun;48(6):594-600
.
Renal amyloidosis in india
Postgraduiate Medical Journal (January 1981) 57, 31-35
Patterns
Glomerular deposits — nephrotic range proteinuria
The urine sediment is benign
Creatinine normal or only moderately elevated.
End-stage renal disease in 20 % with poor prognosis.
Vascular and Tubular amyloid deposits — Prognosis more
favorable.
Tubular dysfunction such as type 1 (distal) renal tubular acidosis
or polyuria due to nephrogenic diabetes insipidus
CARDIAC AMYLOID
Classification
Type
%
Cardiac
involvement(%)
Amyloid
protein
Protein
precursor
Primary
85
33-50
AL
light chain Ig
Familial
10
25
ATTR
Transthyretin
Secondary
Rare
Rare
AA
Apo SAA
Senile
<5
10
ATTR
Transthyretin
Isolated atrial
amyloid
-
-
AANF
ANF
(IHJ : May-Jun 2004,56:3)
Clinical manifestations
• 10% of nonischemic cardiomyopathy
Chest,2003;124:969-977
• Typical picture –rapidly progressive CHF due to
RCMP, but systolic dysfunction occur late
• DCMP– only in 5%
Intern Med ,2000;39:637-640
• Typical angina, Unstable Angina, MI & silent ischemia
Investigations
• Electrocardiogram
•
•
•
•
•
Most characterstic – low voltage ECG(56%)
Pseudoinfarction pattern(60%)
Abnormal axis deviation
Bundle branch blocks
Arrythmias – AF,ventricular arrythmias, conduction
defects
• Sudden cardiac death
Br Heart J 1984;52:233-236
Electrocardiogram
Investigations
• Echocardiography
• Typically increased thickness of left ventricular walls
• Granular sparkling appearance of myocardium
• Dilated atria, interatrial septal hypertrophy (>7mm)
• Small pericardial effusion, thickened valves and thickened Rt.
Ventricular free wall
• Overt heart failure, EF<50% & Ventricular thickening >15 mm
is poor prognostic sign
• Hematol/Oncol Cl North America 13:6:1999
Echocardiogram revealing thickened walls with
small chambers
Thickened ventricles
Small cavity
Granular speckling
Magnetic Resonance Imaging / Biopsy
•Characteristic pattern of global subendocardial late gadolinium
enhancement
•Gadolinium late enhancement can have variable pattern localized or diffuse, and subendocardial or transmural
•Not necessary to biopsy the heart if the echocardiographic
appearances are typical AND a histologic diagnosis has been
made from another tissue.
•Otherwise 100% sensitive if heart involved, useful in localized
type of amyloidosis
•Cardiology in Review Volume 18, Number 1, January/February 2010
GI Amyloid
• Either mucosal infiltration or neuromuscular infiltration.
•Four syndromes: gastrointestinal bleeding, dysmotility,
malabsorption, or protein-losing gastroenteropathy.
•Symptoms- Pain, Perforation, Pseudoobstruction, Gastric and
colonic dilation, Intestinal necrosis, and Chronic diarrhea
•GI Complications not usually the cause of death
• Treat Symptomatically and underlying cause of amyloidosis.
• Mayo Clinic series Medicine (Baltimore) 2003 Sep;82(5):291-8.
Hepatic amyloidosis
•Typically older than 50 and more commonly male in both
AL & AA Amyloidosis.
• Weight loss (72%), fatigue, abdominal pain and
hepatomegaly (81%).
•Most frequently raised alkaline phosphatase level(86%)
•Diagnosis confirmed by tissue biopsy of duodenal or
colorectal mucosa(more sensitive than a fat biopsy).
•Mayo Clinic series Medicine (Baltimore) 2003 Sep;82(5):291-8.
Nervous system
•Mixed sensory and motor peripheral neuropathy and/or
autonomic neuropathy in hereditary and AL amyloidosis.
•Carpal tunnel syndrome
•Sporadic or familial Alzheimer disease, while cerebral
amyloid angiopathy
•Ischemic stroke usually cardioembolic
Musculoskeletal disease
• Macroglossia is
characteristic of AL
amyloid.
• Arthropathy- The
"shoulder pad" sign
characteristic of AL &
beta-2 microglobulin
amyloid.
Hematologic abnormalities
• Bleeding diathesis- 337 patients, bleeding in 28% & abnormal tests
in 51% AL Amyloidosis
•Major mechanisms:
• Factor X deficiency
• Decreased synthesis of coagulation factors in advanced liver
disease.
•Amyloid infiltration of blood vessels
•Bleeding due to acquired von Willebrand disease
Br J Haematol 2000 Aug;110(2):454-60
Pulmonary disease
Presentation
Tracheobronchial infiltration, persistent pleural effusions,
parenchymal nodules (amyloidomas), and (rarely) pulmonary
hypertension.
Symptoms-Hoarseness, stridor, airway obstruction, and dysphagia;
Bronchoscopic or surgical resection
Persistent pleural effusions develop in 1 to 2 percent ,
Thought to be caused by pleural infiltration with amyloid deposits .
Poor prognosis and pleurodesis has been useful in some cases.
Ground glass infiltrates and pleural effusion
amyloidomas
Skin manifestations
•Waxy thickening, subcutaneous
nodules or plaques.
• Purpura in a periorbital distribution
(raccoon eyes) highly characteristic of
AL amyloidosis .
Figure 3
Figure 2
Hemorrhagic lesion over the
mandible in a male patient, the
result of shaving. There is also an
enlarged submental lymph node.
Waxy appearance of
intradermal amyloid deposition
around the eye.
DIAGNOSIS
United Kingdom Myeloma Forum, 2004
Site
Sensitivity
Advantages
(%)
Subcutaneous 80–90
No mortality, little
fat
morbidity
Rectal mucosa 75–85
Routine processing
Salivary gland 75
High sensitivity in single
center
Involved organ 90–100
High sensitivity, high
specificity
Disadvantages
Insensitive in B2M and amyloid
associated with familial
Mediterranean fever
complication (bleeding); must
include vessels
Bone marrow 30–40 in AL Can be assessed at same Not reliable in other than lighttime as presence of
chain amyloidosis
multiple myeloma
Gingiva
15–20
Easily accessible
Insensitive
Stomach
75–85
High sensitivity in single Requires endoscopy
center
Needs confirmation in other
centers and in broader
spectrum of amyloidoses
Occasional serious
complications
Subcutaneous abdominal fat aspiration
The method
• Bed side
• Prepare and
anesthetize sub or
Para-umbilical area
• 19-gauge needle
• Aspirate (>1 mm3)
• Air dry
• Stain
MICROSCOPY
•The amyloid deposits appear
as amorphous hyaline material
on light microscopy
• The fibrils bind Congo red
(leading to green birefringence
under polarized light)
•Thioflavine T (producing an
intense yellow-green
fluorescence)
•Electron microscopy, are 8 to
10 nm in width and straight and
unbranching
Immunohistology
•Used to identify the type of protein subunit with specific
antisera, 10% cross reactivity
•Less useful in AL amyloidosis <50% as loss of binding epitopes
during processes
Scintigraphy with radioisotope
labeled serum amyloid P component
•Identify the distribution of
amyloid, and provide an
estimate of the total body
burden of fibrillar deposits .
•Sensitivity of 90 percent for AA
and AL amyloid ,48 percent for
hereditary ATTR amyloidosis;
the specificity is 93 percent in
all three conditions .
•Less helpful in detecting
cardiac amyloid.
•Potential infectious risk
• Test is more accurate in secondary amyloidosis
•May be positive even when tissue biopsy has been
negative.
•SAP scintigraphy has a sensitivity approaching 100
percent with almost universal splenic uptake, renal
uptake in more than 80 percent, adrenal uptake in 50
percent, and hepatic uptake in 25 to 50 percent.
Micropurification techniques
•Chromatography
•Reversed phase HPLC used for the purification and analysis from
formalin fixed tissues in small amount samples
•Western blotting
•SDS –PAGE based western blotting better approach fresh tissues
because it allows the type, molecular mass, and amount of
amyloid to be determined for adequate amount samples
•PCR based genetic studies for to recognize mutations in
transthyretin , fibrinogen, lysozyme, and apolipoproteins A-I and
A-II.
J Clin Pathol 2003;56:86–90
PARAPROTEINS
Sensitivity-71%
Urine protein electrophoresis
Sensitivity-84%
DISTRIBUTION OF URINE PROTEIN FINDINGS IN AL
AMYLODOSIS
k
None
35
l
Percent
30
25
20
15
10
5
0
0-0.5
0.5-1.0
1.0-3.0
3.0-6.0
6.0-10.0
> 10
g/day
Gertz et al:Amyloidosis AL
Serum free light chain estimation
• This immunoassay can detect and quantify FLC in serum with
high sensitivity and specificity.
• This assay gives positive result ( raised level of either kappa or
lambda together with an altered ratio of free kappa to lambda) in
98% .
• This assay not specific for AL amyloidosis
• Useful in follow up at 3 monthly interval with absolute reduction
more significant than % decrease
•
Clinical Chemistry 47:4 673–680 (2001)
Bone marrow biopsy
• Biopsies should be specifically stained for
amyloid and immunohistology performed with
antibodies to kappa and lambda light chains
to look for clonality of plasma cells.
.
• Presence of a monoclonal protein alone not
sufficient
TREATMENT
N engl j med 356;23 www.nejm.org june 7, 2007
American Journal of Hematology 79:319–328 (2005)
American Journal of Hematology 79:319–328 (2005)
American Journal of Hematology 79:319–328 (2005)
American Journal of Hematology 79:319–328 (2005)
THERAPY
TARGETS
1.DECREASE PRODUCTION OF ANTIBODY
2.STABILISE PROTEIN TO PREVENT MISFOLDING
3.DESTABILIZE GAG BACKBONE
STRATIFY YOUR PATIENT IN ACCORDANCE WITH
RISK
SWISS MED WKLY 2006;136:715–720
Clin J Am Soc Nephrol 1: 1331–1341, 2006.
Clin J Am Soc Nephrol 1: 1331–1341, 2006
BLOOD, 15 JUNE 2002 VOLUME 99, NUMBER 12
Oral melphalan plus prednisone(MP)
•Applicable for poor risk patients.
•Better than colchicine alone or colchicine with MP
•Response rate to MP is approximately 30% and time
to response was longer than 1 year in 30% of cases
Drawback- Slow response
N Engl J Med. 1997;336:1202–7.
Dexamethasone based regimens
•In multiple myeloma, VAD induce a quick response
•Toxic in amyloidosis
•Oral melphalan & dexamethasone
•(MDex) induces a haematological response in 67%
(CR 33%) of AL patients ineligible for ASCT in a median
time of 4.5 months.
•Treatment-related mortality is 4%
Blood. 2004;103:2936–8.
Thalidomide with intermediate dose
dexamethasone (TDex)
•Second-line treatment, failed HSCT, n=14
•Clonal response in 48% of cases, with 19% CR
•Median time to response is 3.6 months.
•Severe adverse events are frequent (65%),
•No treatment-related mortality
•Symptomatic bradycardia is a common (26%) reaction
•Monthly Holter monitoring is useful
Blood. 2005;105:2949–51.
Lenalidomide +/- dexamethasone
• n=34
• Most patient non responder to previous therapies
• Overall response rates for subjects taking both medications
were 67 to 75 percent.
• 42% response if at least one taken
• Better tolerability than thalidomide
Blood. 2007 Jan 15;109(2):492-6
•Cyclophosphamide thalidomide and
dexamethasone (CTD) or aCTD(attenuated)
regimen
• n=75, advanced disease or treatment failure
•Complete response rates in 21 percent
•Grade 1 toxicity in 100%,grade 2 in 52 percent, grade 3 in
32 percent.
•Blood. 2007 Jan 15;109(2):457-64.
Bortezomib and dexamethasone (BD)
• N=18
• Most patient had relapse, treatment failure or
multiorgan involvement
• 94% had a hematologic response and 44% a
hematologic complete response.
• Hematologic responses were rapid (median 0.9
months) and median time to organ response was 4
months
Haematologica 2007 oct;92(10):1302-7.
LOW RISK
INTERMEDIATE RISK
HIGH RISK
•15% of total cases
•Younger than 65 years, with
no major organs involved,
• low NT-proBNP and Cardiac
troponin T
•Creatinine clearance> 50
mL/min,
•Pulmonary diffusion capacity
50% and
•Systolic blood pressure > 90
mmHg)
• SCT with melphalan 200
mg/m2 may be considered as
front-line therapy.
•In patient not achieving
complete response,
thalidomide with
dexamethasone / bortezomib
with dexamethasone can be
trie
•65% of total cases
•Mdex-Used in most cases
• CTD -particularly indicated in
patients eligible for SCT but
refuse the procedure, and in
those in need of a prompt
response.
•Bortezomib +/dexamethasone -High
response rates and rapid
action (less than one month).
•Relapsing and refractory
patients -Bortezomib and
lenalidomide associated with
dexamethasone.
•Advanced cardiac
amyloidosis, Increased
troponin and NT-proBNP
and New York Heart
Association (NYHA) class III or
IV or ECOG performance
status 3
•20% of total cases
•Short median survival (3.5
months), rapid acting therapy
wanted
•MTDa or CTDa and, possibly,
those containing low-dose
(0.7-1.0 mg/m2) bortezomib
• Median survival 1-2 yrs in untreated
Poor prognosis
• Cardiac amyloid(Kyle, 1986)
elevated pro-BNP & troponin
Better prognosis
• Proteinuria as dominant
presentation (Kyle & Gertz,
1995)
• Large whole body amyloid load
on SAP scintigraphy
• Suppression of clonal disease
(Lachmann, 2003)
by chemotherapy
• Autonomic neuropathy
(Rajkumar, 1998)
• Liver & hyperbilirubinemia
(Lovat, 1998)
• Multiple myeloma (Abraham,
2002)
• Regression of deposits on SAP
scintigraphy
TREATMENT AA AMYLOIDOSIS
Eprodisate
•A two-year double-blind multicenter international study
randomly assigned 183 patients with renal AA amyloidosis
•Oral eprodisate Vs placebo
•Reduction in risk of worsening of renal function seen
•No significant difference in mortality, proteinuria, or the tissue
content of AA amyloid.
N Engl J Med 2007; 356:2349.
TRIAL DRUGS
1.
IDOX :
- 4’ Iodo- 4 deoxudoxorubicin
Binds to amyloid fibril causing increased catabolism
2.
CPHPC :
Carboxypyrrolidin oxohexaonylpyrrolidine carboxylic acid
Blocks binding sites of SAP
Cross links pairs of pentameric SAP molecules
3.
FIBRILLEX :
Sodium 1 –3 propane disulfonate
Phase II / III trial drug
Glycosaminoglycan mimetic drug that binds with SAP
4.Diflunisal
•Stabilize the native structure of the precursor protein
and prevent its transition to a misfolded protein.
•familial transthyretin amyloidosis with neuropathy.
•binds to the thyroxine-binding sites of the transthyretin
tetramer.
SUPPORTIVE THERAPY
•ACE inhibitor to be used in lowest doses
•Amiodarone for repetitive ventricular arrhythmias on holter,
ICD controversial
•ICD for recurrent syncope
•Salt restriction & diuresis to be judicious
•Nutritional therapy
•Elastic stockings and midodrine for hypotension
•Dialysis for ESRD
CONCLUSION
•Establishing amyloid type specific
diagnosis is important
•Differentiate other clonal proliferative
disorders from AL amyloidosis
• Difficult to treat disease
•High clinical suspicion required
•Proteomics to play a important role in
diagnosis
•New drugs like bortezomib, lenalidomide
promising
Thank you
REGIMEN
DOSE
mp
prednisone (0.8 mg/kg per day PO for seven days every 6 weeks) plus lowdose oral melphalan (0.15 mg/kg per day PO for the same seven days every 6
weeks)
mdex
melphalan (0.22 mg/kg per day PO on days 1 through 4 every 28 days) are
combined with high dose dexamethasone (40 mg/day PO on days 1 through
4 every 28 days).
Thal dex
thalidomide (initial dose 100 mg/day by mouth at night, with escalation to
400 mg/day if tolerated) was combined with dexamethasone (20 mg/day by
mouth on days 1 through 4 every 21 days)
CTD
21 day cycles including cyclophosphamide (500 mg PO once per week),
thalidomide (initial dose 100 mg/day PO continuously, increased after 4
weeks to 200 mg/day if tolerated), and dexamethasone (40 mg/day PO on
days 1 to 4 and 9 to 12 of each cycle).
aCTD
28 day cycles including cyclophosphamide (500 mg PO on days 1, 8, and 15),
thalidomide (starting dose 50 mg/day PO, increased by 50 mg/day at 4-week
intervals as tolerated), and dexamethasone (20 mg/day PO on days 1 to 4 and
15 to 18).
Len+/-dexa
lenalidomide (initial dose 25 mg/day PO for 21 days of a 28 day cycle) with
or without dexamethasone in patients with AL amyloid
DRUG
toxicity
Bortezomib
Edema (11% to 28%), hypotension (12% to 15%) , Fever (19% to 37%),
psychiatric disturbance (35%), headache (17% to 26%), dysesthesia
(9% to 27%), Rash (17% to 28%), Diarrhea (47% to 57%), nausea (44%
to 57%), Thrombocytopenia (21% to 38%)anemia (17% to 30%,
neutropenia (6% to 19%; peripheral neuropathy (36% to 55%;)bone
pain (2% to 16%)Dyspnea (20% to 23%), synope (2%),Hypercalcemia
(2%)
Adjust for renal, hepatic impairment,old age and leukopenia
Thalidomide
Edema (57%), thrombosis/embolism (23%) hypotension (16%)
Fatigue (79%)dizziness (4% to 20%), sensory neuropathy (54%), Rash
(21% to 31%), Hypocalcemia (72%) ,diarrhea (4% to 19%) Leukopenia
(17% to 35%), neutropenia (31%), anemia (6% to 13%),
lymphadenopathy (6% to 13%) bilirubin increased (14%),Hematuria
(11%),dermatitis
Lenalidomide
Similar but reduced frequency.
Adjust forrenal dysfunction,old age,leukopenia,anemia
CARDIAC AMYLOIDOSIS
Good risk patients
•Younger than 65 years, with no major organs involved,
•NT-proBNP < 332 ng/L,
• Cardiac troponin T < 0.035 μg/L or cardiac troponin I < 0.1μg/L,
•Creatinine clearance 50 mL/min,
•Pulmonary diffusion capacity ³50% and
•Systolic blood pressure > 90 mmHg)
• SCT with melphalan 200 mg/m2 may be considered as frontline therapy.
•15% of total cases
•In patient not achieving complete response, thalidomide with
dexamethasone / bortezomib with dexamethasone can be tried
haematologica | 2009; 94(8)
High risk
•Advanced cardiac amyloidosis, Increased troponin (cTnI >0.1 μg/L
or cTnT >0.035 μg/L) and NT-proBNP (>332 ng/L)
and
• New York Heart Association (NYHA) class III or IV or ECOG
performance status 3 (not due to polyneuropathy)
•20% of total cases
•Short median survival (3.5 months), rapid acting therapy wanted
•MTDa or CTDa and, possibly, those containing low-dose (0.7-1.0
mg/m2) bortezomib
•haematologica | 2009; 94(8)
Intermediate risk
•65% of total cases
•Mdex-Used in most cases
• CTD -particularly indicated in patients eligible for SCT but
refuse the procedure, and in those in need of a prompt
response.
•Bortezomib +/-dexamethasone -High response rates and
rapid action (less than one month).
•Relapsing and refractory patients -Bortezomib and
lenalidomide associated with dexamethasone.
•haematologica | 2009; 94(8)