|
Morie A. Gertz
- 1, Athanasios Anagnostopoulos
- 2, Kenneth Anderson - 3,
Andrew R. Branagan - 3, Morton
Coleman - 4, Stanley R. Frankel
- 5, Sergio Giralt - 2,
Todd Levine - 6, Nikhil Munshi
- 3, Alan Pestronk - 6,
Vincent Rajkumar - 1, and
Steven P. Treon - 3
Mayo Clinic, Rochester, MN, USA1, MD
Anderson Cancer Center, Houston, TX, USA
- 2 , Dana Farber Cancer Institute and Harvard Medical
School, Boston, MA, USA - 3,
Weill Medical College of Cornell University, New York, NY,
USA - 4, Greenebaum Cancer
Center and University of Maryland, Baltimore, MD, USA
- 5, Washington University School of Medicine, St.
Louis, MO, USA - 6
This manuscript represents consensus
recommendations for the treatment of patients with Waldenströmıs
macroglobulinemia (WM), which were prepared in conjunction
with the 2nd International Workshop held in Athens, Greece
during September 2002. The faculty adopted the following
statements for the management of patients with Waldenstromıs
macroglobulinemia:
1. Alkylating agents, nucleoside analogues,
and rituximab are reasonable choices for first line therapy
of WM;
2. Combinations of alkylating agents,
nucleoside analogues, or rituximab should at this time be
encouraged in the context of a clinical trial;
3. In WM, rituximab can cause a sudden
rise in serum IgM and viscosity levels in certain patients
which may lead to complications; therefore, close monitoring
of these parameters and symptoms of hyperviscosity is recommended
for WM patients undergoing rituximab therapy;
4. For relapsed disease, it is reasonable
to use an alternate first-line agent or re-use of the same
agent; however, since autologous stem cell transplantation
may have a role in treating patients with relapsed disease,
it is recommended that patients for whom autologous transplantation
is seriously being considered should have limited exposure
to alkylator or nucleoside analogue drugs.
5. Combination chemotherapy for patients
who can tolerate myelotoxic therapy, thalidomide alone or
with dexamethasone are reasonable choices for relapsed patients.
6. Autologous stem cell transplantation
may be considered for patients with refractory or relapsing
disease.
7. Allogeneic transplantation should
be undertaken only in the context of a clinical trial.
8. Plasmapheresis should be considered
as interim therapy until definitive therapy can be initiated.
9. Rituximab should be considered for
patients with IgM-related neuropathies.
10. Corticosteroids may be useful in
the treatment of symptomatic mixed cryoglobulinemia.
11. Splenectomy is rarely indicated but
has been used to manage painful splenomegaly and hypersplenism.
The Second International Workshop on
Waldenstromıs macroglobulinemia was held in Athens, September
26-30, 2002. This conference brought together a faculty
with extensive clinical and scientific experience in Waldenstromıs
macroglobulinemia. Four consensus panels were convened to
define four specific areas. The charges of the other three
consensus panels were (1) to define clinicopathologically
Waldenstromıs macroglobulinemia, (2) to define the prognostic
markers and the criteria to initiate therapy in Waldenstromıs
macroglobulinemia, and to (4) define uniform response criteria
in Waldenstromıs macroglobulinemia. Consensus panel three
was charged to define treatment recommendations in Waldenstromıs
macroglobulinemia and is the subject of this report.
What are the treatment options
for the first line therapy of Waldenstromıs macroglobulinemia?
Statement 1
Reasonable choices as first line
agents for the therapy of Waldenstromıs macroglobulinemia
include: alkylating agents (e.g. chlorambucil), nucleoside
analogues (cladribine or fludarabine), and the monoclonal
antibody rituximab. There are insufficient data to recommend
the use of one first-line agent over another; however, individual
patient considerations including the presence of cytopenias,
need for rapid disease control, age, and candidacy for autologous
transplant therapy should be weighed in making the choice
of a first-line agent. For patients who are candidates for
high-dose chemotherapy and autologous transplantation, and
for whom such therapy is being seriously considered, exposure
to alkylating or nucleoside analogue therapy should be limited.
Clinical trial participation should be considered a high
priority for this patient population.
Discussion
An extensive body of literature exists
on the use of alkylating agents (1, 2), purine nucleoside
analogs (3-14), and rituximab (15-20); however, no prospective
randomized data exist in the literature to direct a treatment
choice as initial therapy for this disorder. The data are
clear that the use of both alkylating agents and purine
nucleoside analogs can deplete hematopoetic stem cells,
and the long-term use of these therapies is contraindicated
in patients who are candidates for stem cell mobilization
(21, 22).
Statement 2
There are no comparative data to
recommend the use of a particular nucleoside analogue, and
the selection of either cladribine or fludarabine should
be regarded as reasonable choices if nucleoside analogue
therapy is being considered.
Discussion
It is not clear in B-cell CLL whether
the purine-nucleoside analogs are non-cross-resistant agents
(23-24). The published literature does not permit selection
of one agent as a preferred modality (25-26).
Statement 3
There are
no comparative data to recommend the use of alkylating,
nucleoside analogue or monoclonal antibody therapy in combination
with each other, or in combination with another agent at
this time. The use of combination drug therapy should be
undertaken in the context of a clinical trial until more
data are forthcoming. The published response rates to purine
nucleoside analogues range from 31 to 100%. The published
response rates to alkylating agents range from 68 to 100%.
Because of differences in study size and patient population,
these numbers are not directly comparable. For patients
in need of rapid tumor control, purine nucleoside analogues
have been shown to achieve response in a shorter time interval.
Discussion
A small feasibility study has been published
combining cladribine, cyclophosphamide, and/or prednisone
(27, 28). A dose escalation study has also been published
in CLL and non-Hodgkinıs lymphoma (28). These feasibility
studies have been done to establish the dose of combinations
but do not provide information on time to progression and
overall survival to suggest that there is any benefit to
combining active agents as opposed to their sequential use
in the management of Waldenstromıs macroglobulinemia.
Statement 4
Abrupt and transient increases in
serum IgM levels and serum viscosity may occur in some patients
with Waldenstromıs macroglobulinemia who are receiving rituximab
therapy; therefore, close serial monitoring of IgM levels
and serum viscosity, if indicated, should be undertaken
in patients receiving rituximab therapy in view of these
reports.
Discussion
Anecdotal observations of a possible
flare phenomenon after administration of rituximab are reported.
It is unknown whether this is the result of release of intracellular
IgM in the circulation following the destruction of the
lymphoplasmacytic clonal cells. Because of this phenomenon,
it is important that physicians not abandon the therapy
as a failure until sufficient time has passed to allow for
clearance of the IgM monoclonal protein (17, 29).
What
are the treatment options for relapsed and refractory disease
in Waldenstromıs macroglobulinemia?
Statement
5
For patients in relapse or who have
refractory disease, the use of an alternate first line agent
may be reasonable. For patients in relapse who demonstrated
a durable response of one year or more following cessation
of initial therapy, the re-use of the same agent(s) may
also be reasonable. However, for those relapsing patients
for whom high-dose chemotherapy and autologous transplantation
is contemplated, further exposure to stem cell damaging
agents (i.e. many alkylating agents and nucleoside analogue
drugs) should be minimized. Non-stem cell toxic agents such
as rituximab, would be preferable if stem cells have not
been previously harvested.
Discussion
Patients who relapse off therapy with
Waldenstromıs macroglobulinemia frequently maintain their
chemotherapy sensitivity and can have remission re-induced
by the readministration of the identical agent that produced
the first response (30). However, in relapsed disease, preliminary
data suggest that stem cell transplantation may have a role,
and further exposure to stem cell toxic agents should be
avoided if stem cell transplantation is an appropriate consideration
(31, 32, 33).
Statement 6
If the options
in statement 5 are not applicable, limited published reports
suggest that thalidomide as a single agent, and in combination
with dexamethasone and/or clarithromycin is active in Waldenstromıs
macroglobulinemia, and may be a reasonable choice for those
patients who have failed first line therapies, or for those
relapsing patients who are not candidates for alkylating
or nucleoside analogue therapy, or who are pancytopenic.
Myelotoxic
combination chemotherapy (e.g. VBMCP, CVP, CHOP, COP, CAP)
may also be reasonable therapy for those relapsing patients
who can tolerate such therapy.
Limited
published and anecdotal reports suggest that high-dose dexamethasone
or a -interferon therapy may also be of benefit in Waldenstromıs
macroglobulinemia patients, and therefore, may be a reasonable
choice for use in patients who have experienced multiple
relapses or who have pancytopenia that would preclude myelotoxic
therapy. This may be an ideal patient population for participation
in innovative trials of new agents.
Discussion
An extensive body of literature exists
on the use of thalidomide and dexamethasone for the treatment
of multiple myeloma (34, 35). Similar data are now appearing
on the use of these agents for the treatment of Waldenstromıs
macroglobulinemia (36-38). Since these agents produce little
or no myelosuppression, they are particularly well suited
for patients who have extensive marrow infiltration resulting
in dangerous cytopenias that would increase the morbidity
of myelosuppressive chemotherapy.
Is there
a role for high dose chemotherapy and autologous transplant,
allogeneic, and non-myeloablative allogeneic Transplantation?
Statement
7
There is encouraging but no comparative
published data on the use and timing of myelosuppressive
chemotherapy with autologous stem cell support for the treatment
of Waldenstromıs macroglobulinemia, and use of this treatment
modality should be considered for eligible patients with
primary refractory disease, relapsing disease, or complicating
amyloidosis.
Discussion
Since disease recurrence in Waldenstromıs
macroglobulinemia is inevitable and frequently drug resistance
develops, the use of high-dose therapy in an attempt to
overcome drug resistance is reasonable. Small numbers of
patients have been transplanted, and although no comparative
data exist, the reported treatment-related mortality is
low, indicating this technique is worthy of further evaluation
(39).
Statement 8
Encouraging but very limited results
have been reported with the use of allogeneic transplantation
(including non-myeloablative allogeneic transplantation)
in Waldenstromıs macroglobulinemia. In view of the high
mortality and/or morbidity risks associated with these modalities
of therapy, such patients should be treated in the context
of a clinical trial.
Discussion
The median age of patients with Waldenstromıs
macroglobulinemia is 67 years; so the majority of patients
would not be suitable candidates for HLA-matched stem cells
as a source of hematopoietic reconstitution. Although, in
younger patients with macroglobulinemia, instances of successful
allogeneic transplant have been reported (39-41), however,
the known morbidity and mortality and uncertainty of durable
remissions should limit this technique to patients whose
outcomes will ultimately be reported in the peer-reviewed
literature.
Management
of IgM-Related Disorders:
Hyperviscosity,
IgM Neuropathies, Cryoglobulinemia, and Amyloidosis.
Statement
9
The use
of plasmapheresis is indicated for the treatment of symptomatic
hyperviscosity, and limited data support its use for the
treatment of certain complications associated with IgM monoclonal
proteins such as moderate to severe neuropathy, symptomatic
cryoglobulinemia, or light chain cast nephropathy. In such
circumstances, plasmapheresis should be regarded as interim
therapy until definitive therapy can be initiated and shown
to control disease.
Rituximab
has been reported to be of benefit in patients with IgM
autoantibody-related neuropathies and may be regarded as
a reasonable choice for treating patients who demonstrate
clinical or laboratory evidence of moderate to severe IgM
autoantibody-related neuropathies. For patients with mild
IgM neuropathies, the use of supportive measures including
the use of analgesics, anticonvulsants such as gabapentin,
and antidepressants such as amitriptyline may be incorporated.
Patients should be encouraged to participate in clinical
trials.
Discussion
Plasmapheresis has been demonstrated
to successfully reduce the complications and morbidity associated
with hyperviscosity (42-44). Hyperviscosity is a direct
result of immunoglobulin production by the tumor clone;
therefore, cytoreductive therapy should be considered the
primary modality of managing hyperviscosity, and plasma
exchange should be considered an interim management tool
to prevent life-threatening hemorrhage or irreversible central
nervous system complications while primary therapy is used
to reduce the production of the IgM monoclonal protein.
Peripheral neuropathy is a serious and disabling complication
associated with IgM monoclonal gammopathies. Plasmapheresis
has been demonstrated to produce symptomatic and objective
benefit in these patients and is valuable in the management
of this problem (45-48).
Patients with IgM-associated disorders
such as neuropathy do not generally fulfill the criteria
for an overt malignancy. Their bone marrow will demonstrate
only small numbers of clonal lymphocytes/plasma cells, and
they will not have associated anemia or lymphadenopathy
as is seen in Waldenstromıs macroglobulinemia. Cytotoxic
chemotherapy may be inappropriate because the clinical course
will be dominated by the neurologic syndrome. Therapies
that do not carry a risk of secondary malignancy or long-term
immunosuppression such as Rituximab have been reported to
successfully lead to regression of neuropathy, although
its use is usually unnecessary in patients whose symptoms
are limited to mild paresthesias limited to the feet without
evidence of motor changes (49-52).
Statement 10
The use of corticosteroids in symptomatic
Waldenstromıs macroglobulinemia and IgM-related disorders
in patients with symptomatic mixed cryoglobulinemia with
immune complex deposition may be of particular benefit based
on limited published experiences.
Discussion
IgM monoclonal gammopathies are invariably
present in type II mixed cryoglobulinemia. This immune complex
disorder results in systemic vasculitis involving the skin,
the kidneys, the liver, and the joints. The primary therapy
in patients with hepatitis-associated cryoglobulinemia is
interferon. However, deposition of immune complexes resulting
in significant morbidity can be effectively managed with
the use of high-dose corticosteroid therapy. It is important
to recognize that patients with IgM monoclonal gammopathies
may have an associated cryoglobulinemia with immune-related
manifestations unrelated to overall tumor mass (53-56).
Is there
a role for splenectomy in the management of Waldenstromıs
macroglobulinemia?
Statement
11
Splenectomy is rarely indicated,
but limited case reports exist suggesting it may be helpful
for managing symptomatic splenomegaly including hypersplenism
and painful splenomegaly.
Discussion
Splenectomy does not address the primary
issues of Waldenstromıs macroglobulinemia, that being the
direct marrow infiltration with lymphoplasmacytic cells.
Rare patients have been reported in whom splenectomy has
led to a hematologic response. Patients have been reported
with massive splenomegaly where splenectomy led to disappearance
of the monoclonal IgM. Splenectomy can be considered in
patients who have severe cytopenias that would increase
the risk of cytotoxic drugs or have symptoms related to
their enlarged spleen (57-59).
Concluding Comments
Clear-cut guidelines cannot be issued
for all patients because of the lack of randomized phase
three studies. The mainstays of therapy remain alkylating
agents and purine nucleoside analogues usually administered
singly or in sequence. The data does not permit selection
of one modality over another. Whether combinations will
be shown to be superior to sequential single agents is unknown.
The ultimate role of rituximab in the management of Waldenstromıs
macroglobulinemia remains to be defined. The hope is that
new targeted therapy may improve the outcome for macroglobulinemia
patients. Further revisions of these guidelines are planned
at the next Waldenstromıs International Workshop to be held
in 2004.
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