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Ed Forum 2018

WM Medical Practice Guidelines & Research Articles

Ibrutinib monotherapy outside of clinical trial setting in Waldenstrom macroglobulinemia: practice patterns, toxicities, and outcomes. Abeykoon JP, Saurabh Z, Ansell SM, Gertz MA, Kumar S, Manske M, Novak AJ, King R, Greipp P, Go R, Inwards D, Muchtar E, Habermann T, Witzig TE, Thompson CA, Dingli D, Lacy MQ, Leung N, Dispenzieri A, Gonsalves W, Warsame R, Kyle RA, Rajkumar V, Parikh SA, and Kapoor P. 2019 BR J Haematol. doi-org.pitt.idm.oclc.org/10.1111/bjh.16168.  In this Mayo Clinic retrospective study of 80 patients who received ibrutinib for WM, the researchers found that ibrutinib is an effective drug for previously treated and treatment naïve MYD88L265P mutant WM. Other noteworthy findings include the unique rebound phenomenon associated with abrupt discontinuation of ibrutinib in patients with WM, toxicities, such as atrial fibrillation, as well as the poor outcomes of patients following ibrutinib discontinuation. It should be noted that ibrutinib was generally well tolerated in their study, but 18% of patients required dose reduction and 21% discontinued the therapy for reasons other than disease progression.

Gait speed, grip strength, and clinical outcomes in older patients with hematological malignancies. Liu MA, DuMontier, C, Murillo A, Hshieh TT, Bean JF, Soiffer RJ, Stone RM, Abel GA, Driver JA. Blood 2019;134(4):374-382. doi:10.1182/blood.2019000758. Gait speed is a marker of frailty and can independently predict survival and hospital utilization among older patients with blood cancers, including WM. Decreased grip strength was associated with worse survival, but not hospital utilization.

CXCR4 mutation subtypes impact response and survival outcomes in patients with Waldenstrom macroglobulinemia treated with ibrutinib. Castillo JJ, Xu L, Gustine JN, Keezer A, et al. 2019, Br J Haematol. doi:10.1111/bjh.16088 The results of this study suggest different response and progression free survival rates to ibrutinib for patients with WM with CXCR4NS (nonsense mutation) and CXCR4FS  (frameshift mutation), and advocate in favor of CXCR4 mutational testing as well as CXCR4-directed therapy.

Targeting IL-6 receptor reduces IgM levels and tumor growth in Waldenstrom macroglobulinemia. Han W, Matissek SJ, Jackson DA, Skiavanitis B, Elsawa SF. Oncotarget, 2019, 10(36), 3400-3407. Their data found that administration of Tocilizzumab to tumor bearing mice results in significant reduction in tumor volume and IgM secretion. The evaluation of the role of Tocilizzumab in patients with WM may provide therapeutic efficacy by reducing IgM production and slowing the rate of tumor growth. This research was funded in part by the IWMF.

Updates in prognostication and treatment of Waldenstrom’s macroglobulinemia. Advani P, Paulus A, Ailawadhi S. Hematology/Oncology and Stem Cell Therapy, May 2019, doi.org/10.1016/j.hemonc.2019.05.002 Recently, there has been an increase in research dedicated to WM that better explains the pathobiology of the disease. Researchers have identified several clinical and genetic markers that serve to prognosticate disease course and patient outcomes. This has led to dedicated clinical trials and the development of novel drugs/regimens. This review article from Mayo, Jacksonville aims to document some of the recent advancements with respect to prognostic markers and therapeutic options for patients with WM, as well as certain selected novel treatments with unique mechanisms of action, that are currently under development.

Current therapeutic options in Waldenstrom macroglobulinemia. Zanwar S, Abeykoon JP, Kapoor P. Oncology & Hematology Review. May 2019, 15(1):39-47. In this review, the authors summarize the implications of the different mutational profiles in WM, elaborate on the expanding therapies for WM, and discuss the factors that guide frontline and relapse/refractory therapy.

Targeting IL-6 receptor reduces IgM levels and tumor growth in Waldenstrom macroglobulinemia. Han, W, Matissek SJ, Jackson DA, Sklavanitis B, Elsawa SF. Oncotarget, 2019, 10(36):3400-3407. In Waldenstrom macroglobulinemia (WM), the tumor microenvironment (TME) modulates WM biology by secreting cytokines that promote the malignant phenotype. In previous work, the researchers have shown that TME-IL-6 promotes WM cell growth and IgM secretion in WM. Tocilizumab/Actemra is an anti-IL-6R antibody, which can competitively block IL-6 binding to the IL-6R. The authors investigated the efficacy of Tocilizumab in a preclinical mouse model of WM that considers the role of the TME in disease biology.  They found that administration of Tocilizumab to tumor bearing mice, results in a significant reduction in tumor volume and IgM secretion. Therefore, the evaluation of the role of Tocilizumab in WM patients may provide therapeutic efficacy by reducing IgM production and slowing the rate of tumor growth. This research was funded in part by the IWMF.

Progression risk stratification of asymptomatic Waldenstrom macroglobulinemia. Bustoros M, Sklavenitis-Pistofidis R, Kapoor P, et al. J Clin Oncol 2019 DOI doi.org/10.1200/JCO.19.00394. The researchers studied 439 patients with asymptomatic Waldenstrom macroglobulinemia (AWM), who were diagnosed and observed at Dana-Farber Cancer Institute. Two different AWM cohorts were used for external validation; Mayo Clinic, Rochester MN and Clinical Therapeutics, National and Kapodistrian University of Athens, Greece. During the 23-year study period, with a mean follow-up of 7.8 years, 317 patients progressed to symptomatic Waldenstrom macroglobulinemia (72%). To assess progression risk in patients with AWM, they used a proportional hazards model using bone marrow infiltration, immunoglobulin M, albumin, and beta-2 microglobulin values as measures. The model divided the cohort into three distinct risk groups: a high-risk group with a median time to progression (TTP) of 1.8 years, an intermediate-risk group with a median TTP of 4.8 years, and a low-risk group with a median TTP of 9.3 years. This classification system is useful for patient monitoring and care and, for the first time, to identify patients with high-risk AWM who may need closer follow-up or benefit from early intervention. The research leading to this risk stratification was funded in part by the IWMF. Note - try out their predictive model yourself - go to the website they created for it.  The Markers they are focusing on in their predictive model are levels of:
* Bone Marrow Infiltration, * IgM Protein Level, * Beta2-Microglobulin Level, * Albumin Level.
Their model provides a quick way to analyze whether an asymptomatic patient is in a low risk, medium risk, or high risk of progression to needing treatment. The analysis they performed provide "statistical medians" in terms of time to progression in each category, so there would be an equal probability of someone progressing in less than the stated mean time period and in someone progressing in longer than the stated time period.

Importance of sequential analysis of TP53 variation in patients with Waldenstrom Macroglobulinaemia. Christian A, Davis Z, Walewska R, McCarthy H. Brit J of Haematology 2019, doi: 10.1111/bjh.15909. This pilot study targeted next generation sequencing (NGS) to test for TP53 variation in WM patients. Despite the small cohort size, a variant was detected in 4/14 (29%) patients. Two patients with a TP53 variant progressed while on BTK therapy and both patients were MYD88L265P negative and ibrutinib was insufficient to control progression. While TP53 may not be the contributing factor to therapy resistance, it may be an indicator of genomic instability. The development of TP53 variation over time indicates that TP53 gene testing should be performed to guide therapy choice and identify genetically high-risk patients. This could be performed as part of a panel to include the pertinent genes involved in WM, such as MYD88, CXCR4 and BTK. This study has also shown that targeted NGS has a greater potential for use in a clinical laboratory, showing that liquid biopsies can be used to monitor patients for TP53 variation. This would enable regular monitoring of patient disease while eliminating the need for repetitive invasive bone marrow testing. Further longitudinal studies of these patients in a larger multicenter setting are required to further elucidate the incidence and significance of acquired TP53 variation.

Serum cytokine patterns in immunoglobulin m monoclonal gammopathy‐associated polyneuropathy. Stork A, Rijkers G, Vlam L, Cats E, de Jong B, Fritsch‐Stork R, Veldink J, van den Berg L, Notermans N, van der Pol W-L. Muscle Nerve, 2019 doi:10.1002/mus.26462 Polyneuropathy with immunoglobulin M monoclonal gammopathy (IgM‐PNP) is associated with the presence of IgM antibodies against nerve constituents such as myelin associated glycoprotein (MAG) and gangliosides. The pathogenesis of IgM‐PNP is probably dominated by B cells or plasma cells because evidence for T‐cell involvement is lacking. The mechanisms underlying B‐cell activation and pathogenic antibody production that ultimately cause nerve damage are largely unknown. Immunoglobulin M monoclonal gammopathy‐associated polyneuropathy does not respond to treatments that have been successfully used for other demyelinating neuropathies, including intravenous immunoglobulin (IVIg) and cyclophosphamide given with prednisone. Cytokine expression patterns may suggest specific pathophysiological pathways that could help to design novel treatment strategies. To test whether B‐cell‐stimulating cytokines are increased in IgM‐PNP, the researchers measured serum concentrations of 11 cytokines in 81 patients with IgM‐PNP and 113 controls. They found median IL‐6 and IL‐10 serum concentrations differ between patients with anti‐MAG neuropathy and other patients with IgM‐PNP compared with healthy and neuropathy controls. These differences may indicate differences in immune‐mediated disease mechanisms. 

Prevalence and survival of smouldering Waldenstrom macroglobulinaemia in the United States. Pophali PA, Bartley A, Kapoor P, et al. Br J Haematol 2019; 184:1014. Using the data on WM from the 2004-2012 US National Cancer Database (NCDB) the researchers determined that approximately one in three or 28% of WM cases are smoldering at diagnosis. The 5-year conditional survival for smoldering WM of 70% is similar to ~80% in institutional reports with males have a 3-fold higher relative risk of progression to symptomatic disease compared to females, which is in agreement with this study’s results of longer survival in females. In a Surveillance, Epidemiology and End Results (SEER) study of WM (active + smoldering), older age, male sex and black race were associated with worse outcomes. Using the NCDB, these authors show that outcomes in smoldering WM are also associated with age and sex, but not with race. These proportion and survival rates vary by demographics.

Management of Immunotherapy-Related Toxicities, Version 1.2019. Thompson JA, Schneider BJ, Brahmer J, et al. J Natl Compr Canc Netw 2019;17(3):255-289 doi.org/10.6004/jnccn.2019.0013  These NCCN Guidelines provide guidance on the management of immune-related adverse events resulting from cancer immunotherapy. Medical and hematologic oncologists with experts from the fields of dermatology, gastroenterology, nephrology, emergency medicine, cardiology, oncology nursing, and patient advocacy present a consensus of the currently accepted approaches to treatment. The content featured in this issue is an excerpt of the recommendations for managing toxicity related to immune checkpoint blockage and a review of existing evidence. 

How Recent Advances in Biology of Waldenstrom’s Macroglobulinemia May Affect Therapy Strategy. Baron M, Simon L, Poulain S, Leblond V. Curr Oncol Rep (2019) 21: 27. doi.org/10.1007/s11912-019-0768-4  Recently, WM has been described as a new oncogenic model. MyD88 mutation has been described as a key driver mutation and has functional consequences which could be targeted. Other mutations, such as CXCR4 or TP53, have been reported. These mutations are associated with different clinical presentation, prognosis, and treatment response. Mutational status may influence therapeutic choice in some patients, but additional data are required. New targeted therapies are on development.

CD13 expression in B cell malignancies is a hallmark of plasmacytic differentiation. Raimbault A, Machherndl-Spandl S, Itzykson R, Clauser S, Chapuis N, Mathis S, Lauf J, Alary A-S, Burroni B, Kosmider O, Fontenay M, Bene MC, Durrieu F, Bettelheim P, Bardet V. Brit J Haematology, 2019, 184, 625-633. doi.org/10.1111/bjh.15584  The diagnosis of Waldenstrom Macroglobulinaemia (WM)/lymphoplasmacytic lymphoma (LPL) remains one of exclusion because other B‐cell lymphoproliferative disorders (B‐LPD), such as marginal zone lymphoma (MZL), can fulfil similar criteria, including MYD88L265P mutation. It has been suggested that expression of the myeloid marker CD13 is more frequent in LPL than in other B‐LPD and has also been described on normal and malignant plasma cells. Here, the authors tested CD13 expression in a cohort of 1037 B‐LPD patients from 3 centers by flow cytometry. Their results suggest that testing for CD13 expression in routine flow cytometry panels could help to discriminate WM/LPL from other B‐LPD.

Ibrutinib for the treatment of Bing-Neel syndrome: A multicenter study. Castillo JJ, Itchaki G, Paludo J, Varettoni M, Buske C, Eyre TA, Chavez JC, Shain KH, Issa S, Palomba ML, Pasvolsky O, Simpson D, Talaulikar D, Tam CS, Tedeschi A, Ansell SM, Nayak L, Treon SP. Blood. 2019;133(4):299-305. In this multicenter study ibrutinib was administered to 28 patients with Bing-Neel syndrome. The oral Bruton tyrosine kinase (BTK) inhibitor showed rapid and durable symptomatic and radiologic responses in patients with the syndrome. The authors conclude that ibrutinib therapy is effective in patients with Bing-Neel syndrome and should be considered as a treatment option in these patients.

Dose-limiting stomatitis associated with ibrutinib therapy: a case series. Vigarios E, Beylot-Barry M, Jegou MH, Oberic L, Ysebaert L, Sibaud V. Brit J of Haematology 2018, doi 10.1111/bjh.15620 Ibrutinib can trigger severe impairing stomatitis (an oral toxicity of the tongue and oral mucosa with ontense pain, difficulty swallowing, and subsequent weight loss) that may require temporary discontinuation of the drug. Lesions can develop after several months of treatment. The authors recommend topical or short courses of systemic corticosteroids for managing oral ulcers and relieving pain, once an active infection has been ruled out. The clinical outcomes observed in their patients (with CLL) suggest that ibrutinib may be resumed at a lower dose, without any recurrence.

Risk of Herpes Zoster Prior to and Following Cancer Diagnosis and Treatment: A Population-Based Prospective Cohort Study. Qian J, Heywood AE, Karki S, Banks E, Macartney K, Chantrill L, Liu B. The Journal of Infectious Diseases, 2018  jiy625, doi.org/10.1093/infdis/jiy625 In this analysis of data from 240,000 older adults with over 8 years of follow-up, the authors found that a diagnosis of cancer was associated with about a 40% higher risk of developing zoster compared to those without cancer. The risk was substantially greater among those with hematological cancers compared to those with solid organ cancers. For both types of cancer, risks were highest in the first year following diagnosis, decreasing thereafter.

Two high-risk susceptibility loci at 6p25.3 and 14q32.13 for Waldenstrom macroglobulinemia. McMaster ML, Berndt SI, Zhang J, Slager SL, et al. Nat Comm (2018)9:4182. DOI: 10.1038/s41467-018-06541-2. Characterizing the genetic factors influencing susceptibility to WM/LPL is an important step toward understanding its etiology. To discover genetic loci for WM/LPL susceptibility, the researchers performed a two-stage genome-wide association study of WM/LPL, leveraging a family-based oversampling approach in the discovery followed by replication in an independent, predominantly non-familial, cohort. They report new susceptibility loci at 6p25.3 and 14q32.13 for WM/LPL and provide insights into the genetic etiology of this distinctive B-cell lymphoma.

Evaluating Progression-Free Survival as a Surrogate Outcome for Health-Related Quality of Life in Oncology: A Systematic Review and Quantitative Analysis. Kovic B, Jin X, Kennedy SA, Hylands M, Pedziwiatr M, Kuriyama A, Gomaa H, Lee Y, Katsura M, Tada M, Hong BY, Cho SM, Hong PJ, Yu AM, Sivji Y, Toma A, Xie L, Tsoi L, Waligora M, Prasad M, Bhatnagar N, Thabane L, Brundage M, Guyatt G, Xie F. JAMA Intern Med. 2018 Dec 1;178(12):1586-1596. doi: 10.1001/jamainternmed.2018.4710. Progression-free survival (PFS) has become a commonly used outcome to assess the efficacy of new cancer drugs.  The researchers aimed to answer how strongly is progression-free survival (PFS) associated with health-related quality of life (HRQoL) in studies of cancer treatments. This systematic review and quantitative analysis of 52 articles reporting on 38 randomized clinical cancer trials did not find a significant association between PFS and HRQoL. These findings raise questions about the assumption that interventions prolonging PFS also improve HRQoL in patients with cancer and suggest that HRQoL should be measured directly and accurately, with adequate follow-up time, in future studies.

Bendamustine and rituximab (BR) versus dexamethasone, rituximab, and cyclophosphamide (DRC) in patients with Waldenstrom macroglobulinemia. Paludo J, Abeykoon JP, Shreders A, Ansell SM, et al. Ann Hematol (2018) 97: 1417. doi.org/10.1007/s00277-018-3311-z The treatment approaches for Waldenstrom macroglobulinemia (WM) are largely based upon information from single-arm phase II trials, without comparative data. The researchers compared the efficacy of two commonly used regimens in routine practice (bendamustine-rituximab (BR) and dexamethasone, rituximab plus cyclophosphamide (DRC)) and evaluated their activity with respect to the patients’ MYD88L265P mutation status. A trend for longer progression free survival was observed with BR, although the regimens have comparable toxicities. The activity of BR and DRC appears to be unaffected by patients’ MYD88 mutation. status.

Carfilzomib-based combination regimens are highly effective frontline therapies for multiple myeloma and Waldenstrom’s macroglobulinemia. Chaudhry M, Steiner R, Claussen C, Patel K, Lee H, Weber D, Thomas S, Feng C, Amini B, Orlowski R, Feng L, Manasanch EE, (2018) Leukemia & Lymphoma, DOI: 10.1080/10428194.2018.1508668. The authors conducted a retrospective study to report the efficacy and safety of frontline carfilzomib-based combinations in a standard of care setting. They identified newly diagnosed multiple myeloma (MM) and Waldenstrom’s macroglobulinemia (WM) patients treated with carfilzomib as initial therapy who met study inclusion criteria. The clinical benefit for WM was 100% with all patients having a resolution of B symptoms and anemia after treatment. The authors conclude that carfilzomib-based regimens are well tolerated and offer a neuropathy sparing approach with excellent responses, both in newly diagnosed MM and WM, making them a good choice for the frontline treatment of these diseases.

Prognostic factors and primary treatment for Waldenstrom’s macroglobulinemia – a Swedish Lymphoma Registry Study.  Brandefors L, Melin L, Lindh J, Lundqvist K, Kimby E. British Journal of Haematology, 2018, DOI: 10.1111/bjh.15558. The authors present a nationwide prospective physician led Swedish registry-based study of Waldenstrom macroglobulinemia (WM) that focuses on incidence and survival in relation to clinical prognostic factors and primary therapies. A retrospective review showed that 981 patients fulfilled the World Health Organization diagnostic criteria for WM and these patients were analyzed further. The overall survival (OS) improved between two periods, 2000–2006 and 2007–2014, with a five year OS of 61% and 70%, respectively. Significant prognostic factors for OS, evaluated at the time of diagnosis, were age, elevated lactate dehydrogenase level and hemoglobin ≤115 g/l for patients receiving therapy 0–3 months after diagnosis, and age, poor performance status, hemoglobin ≤115 g/l,  and female sex in “watch and wait” patients (multivariable analysis). The level of the IgM monoclonal immunoglobulin had no significant prognostic value. Rituximab included in first-line therapy was associated with improved survival.

MYD88 mutated and wild-type Waldenström’s Macroglobulinemia: characterization of chromosome 6q gene losses and their mutual exclusivity with mutations in CXCR4. Guerrera ML, Tsakmaklis N, Xu L, Yang G, Demos M, Kofides A, Chan GG, Manning RJ, Liu X, Chen JG, Munshi M, Patterson CJ, Castillo JJ, Dubeau T, Gustine J, Carrasco RD, Arcaini L, Varettoni M,  Cazzola M, Treon SP, Hunter ZR. Haematologica Sep 2018, 103 (9) e408-e411; DOI: 10.3324/haematol.2018.190181. The authors identified 19 genes co-regulated by 6qdel and CXCR4 mutation status, which may be involved in WM clonal evolution. Their findings provide new insights into WM pathogenesis, including loss of key regulators of BTK, apoptosis, BCL2 and NF-κB signaling in asymptomatic and symptomatic WM patients, and shared regulatory signaling for MYD88 mutated WM patients with either 6qdel or CXCR4 mutated disease.

Treatment and outcome patterns in European patients with Waldenström's macroglobulinaemia: a large, observational, retrospective chart review. Buske C, Sadullah S, Kastritis E, Tedeschi A, García-Sanz R, Bolkun L, Leleu X, Willenbacher W, Hájek R, Minnema MC, Cheng M, Bilotti E, Graef T, Dimoupoulos A. Lancet Haematol July 2018, 5(7);e299-e309. In this large, observational, retrospective chart review, academic and community physicians in ten European countries retrospectively completed electronic records for patients with symptomatic Waldenström’s macroglobulinemia who had begun treatment 2000-2014, and had available clinical and biological data. They assessed the variables that affected choice of front-line therapy, progression-free survival, and overall survival in multivariate analyses. This large observational dataset should inform and help set guidelines, and improve understanding of treatment practices and outcomes, for European patients with Waldenström’s macroglobulinemia.

Waldenström’s macroglobulinaemia: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Kastritis E, Leblond V, Dimopoulos M A, Kimby E, Staber P, Kersten M J, Tedeschi A, Buske C, ESMO Guidelines Committee 2018, Annals of Oncology  dy146, doi.org/10.1093/annonc/mdy146. The European Society for Medical Oncology (ESMO) published new guidelines for diagnosis, treatment, and follow up for patients with WM in European practices.

Ibrutinib Monotherapy in Symptomatic, Treatment-Naïve Patients with Waldenström Macroglobulinemia. Treon SP, Gustine J, Meid K, Yang G, Xu L, Liu X, Demos M, Kofides A, Tsalmaklis N, Chen JG, Munshi M, Chan G, Dubeau T, Raje N, Yee A, O’Donnell E, Hunter ZR, Castillo JJ. 2018 J Clin Oncology DOI: doi.org/10.1200/JCO.2018.78.6426. The authors report on a prospective study of ibrutinib monotherapy in symptomatic, untreated patients with WM, and the effect of CXCR4 mutation status on outcome. Thirty patients with WM received ibrutinib. All carried MYD88 mutation and 14 (47%) carried a CXCR4 mutation. Overall and major responses for all patients were 100% and 83%, respectively. Rates of major (94% v 71%) and very good partial (31 v 7%) responses were higher and time to major responses more rapid (1.8 v 7.3 months; P = 0.01) in patients with wild-type CXCR4 versus those with CXCR4 mutation, respectively. The 18-month, estimated progression-free survival is 92%. All patients are alive. Grade 2/3 treatment-related toxicities in > 5% of patients included arthralgia (7%), bruising (7%), neutropenia (7%), upper respiratory tract infection (7%), urinary tract infection (7%), atrial fibrillation (10%), and hypertension (13%). There were no grade 4 or unexpected toxicities. It was concluded that ibrutinib is highly active, produces durable responses, and is safe as primary therapy in patients with symptomatic WM. CXCR4 mutation status affects responses to ibrutinib.

Selecting Initial Therapy for Newly Diagnosed Waldenström Macroglobulinemia, Editorial. Gertz MA, 2018 J Clin Oncology 2018 ascopubs.org/doi/abs/10.1200/JCO.2018.79.3273 This editorial accompanies the Treon publication on newly diagnosed patients with WM treated with ibrutinib (see above) and references the Dimopoulos and colleagues iNNOVATE Study of ibrutinib or placebo in combination with rituximab in subjects with WM (see elsewhere on this page). He suggests that all initial combination therapies seem to be highly effective, with clear superiority over single-agent rituximab, which should no longer be considered appropriate initial therapy for this disorder.  He goes on to question how one decides among available therapies given the side effects, age of the patient at diagnosis, fixed duration therapy vs. the need for continuous therapy until progression, and cost as a barrier to access. He adds that it is important to have multiple options, and ibrutinib with its high activity is a welcome addition to the current armamentarium. He ends with a discussion of new drugs on the horizon and concludes that, “the future is bright for patients with WM who now have many choices for treatment type, and the likely outcome is that few patients will succumb to this disease in the future.”

Prospective Clinical Trial of Ixazomib, Dexamethasone, and Rituximab as Primary Therapy in Waldenström Macroglobulinemia. Castillo JJ, Meid K, Gustine JN, Dubeau T, Severns P, Hunter ZR, Yang G, Xu L, and Treon SP. Clin Cancer Res July 2018; 24(14); 3247-52. DOI: 10.1158/1078-0432.CCR-18-0152. This Dana Farber Cancer Institute group reports results of a prospective phase II study evaluating ixazomib, dexamethasone, and rituximab (IDR) as primary therapy in symptomatic patients with WM. All patients had MYD88 L265P mutation, and 58% of patients had a CXCR4 mutation. The median time to response was 8 weeks, which was longer (12 weeks) in WM patients with CXCR4 mutations. The overall response rate was 96%, and the major response rate was 77%. The median follow-up was 22 months. Adverse events included infusion-related reactions (19%), rash (8%), and insomnia (8%).  IDR offers a highly effective and well tolerated, neuropathy sparing regimen for primary therapy in patients with WM.

A head-to-head Phase III study comparing zanubrutinib versus ibrutinib in patients with Waldenström macroglobulinemia. Tam CS, LeBlond V, Novotny W, Owen RG, Tedeschi A, Atwal S, Cohen A, Huang J, Buske C. Future Oncol. 2018 Jun 5. doi: 10.2217/fon-2018-0163. [Epub ahead of print]. This is a head-to-head Phase III study comparing efficacy and safety of zanubrutinib and ibrutinib in WM patients. WM is sensitive to Bruton tyrosine kinase (BTK) inhibition with ibrutinib, a first-generation BTK inhibitor. Side effects of ibrutinib against TEC- and EGFR-family kinases are implicated in some adverse events. Patients with CXCR4WHIM and MYD88L265P mutations or who are MYD88WT have less sensitivity to ibrutinib than those with MYD88L265Pand CXCR4WT disease. Zanubrutinib, a next-generation BTK inhibitor with potent preclinical activity in WM and minimal side effects, showed sustained BTK occupancy in peripheral blood mononuclear cells from patients with B-cell malignancies and promising responses in advanced WM.

Fifty-Year Incidence of Waldenstrom Macroglobulinemia in Olmsted County, Minnesota, From 1961 Through 2010: A Population-Based Study With Complete Case Capture and Hematopathologic Review. Kyle RA, Larson DR, McPhail ED, Therneau TM, Dispenzieri  A, Kumar S, Kapoor P, Cerhan  JR and Rajkumar SV.  Mayo Clin Proc.  June 2018;93(6):739-746  doi.org/10.1016/j.mayocp.2018.02.011. This study is the first epidemiological study to evaluate the clinical, laboratory, and pathologic features of WM in a specifically prescribed area and time of diagnosis. Patients with smoldering WM, lymphoplasmacytic lymphoma with an IgG or IgA monoclonal protein, and those with an IgM monoclonal gammopathy of undetermined significance were excluded from the study.  Results show Waldenstrom macroglobulinemia is a rare malignancy with an incidence of approximately 0.6 per 100,000 person-years, which is severalfold lower than that of multiple myeloma. The incidence of WM increased with age and the incidence of this disease has not changed during the past half century. Patients diagnosed with WM after 2000 had an approximately 2-fold excess mortality compared with the expected population mortality. Infection was the major cause of death. Most patients who died had advanced, symptomatic WM in addition to the immediate causes of death.

Phase 3 Trial of Ibrutinib plus Rituximab in Waldenström’s Macroglobulinemia. Dimopoulos MA, Tedeschi A, Trotman J, García‑Sanz R, Macdonald D, Leblond V, Mahe B, Herbaux C,  Tam C,  Orsucci L, Palomba ML, Matous JV,  Shustik C, Kastritis E, Treon SP,  Li J, Salman Z,  Graef T, and C. Buske, for the iNNOVATE Study Group and the European Consortium for Waldenström’s Macroglobulinemia. N Engl J Med 2018; 378:2399-2410 DOI: 10.1056/NEJMoa1802917. Among patients with Waldenström’s macroglobulinemia, the use of ibrutinib– rituximab resulted in significantly higher rates of progression-free survival than the use of placebo–rituximab, both among those who had received no previous treatment and among those with disease recurrence. Atrial fibrillation and hypertension were more common with ibrutinib–rituximab, whereas infusion reactions and IgM flare were more common with placebo–rituximab.

Immunizing Cancer Patients: Which Patients? Which Vaccines? When to Give? Shah MK, Kamboj M. Oncology May 2018;32(5):254-8. Patients receiving treatment for cancer should be considered for age- and indication-appropriate vaccinations, and the responsibility for administration of these vaccines is shared between the oncologist and the primary care provider. Certain vaccine-preventable diseases have higher incidence rates among cancer patients and are associated with worse clinical outcomes. The Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices recommend certain vaccines for routine use in adults, including those with cancer. This article provides guidance to oncology clinicians on vaccine recommendations and safety of use in their patients. Key Points are: (1) Indicated vaccines are ideally administered before cancer treatment is initiated. (2) Live vaccines are contraindicated due to risk of severe vaccine-induced infection. (3) Injectable influenza vaccine is given annually, and both pneumococcal vaccines should be administered according to the recommended schedule from the Centers for Disease Control and Prevention. (4) The newer recombinant vaccine (RZV) is the safer and preferred vaccine. (5) Family members and close contacts of cancer patients can be safely immunized with most, but not all, live vaccines.

Impact of Ibrutinib dose intensity on patient outcomes in previously treated Waldenström macroglobulinemia. Castillo JJ, Gustine JN, Meid K, Dubeau TE, Xu L, Yang G, Hunter ZR, Advani R,  Palomba L, and Treon SP. Haematologica May 2018: haematol.2018.191999; Doi:10.3324/haematol.2018.191999. This multicenter study suggests that, similar to CLL patients, low dose intensity adversely impacts progression free survival in WM patients. Ibrutinib therapy is indefinite and compliance should be strongly emphasized to optimize outcomes.

Ibrutinib Withdrawal Symptoms In Patients With Waldenström Macroglobulinemia. Castillo JJ, Gustine JN, Meid K, Dubeau T, Severns, P, Treon SP.  Haematologica February 2018 : haematol.2017.186908; Doi:10.3324/haematol.2017.186908. Ibrutinib is the first approved therapy for the treatment of patients with Waldenström macroglobulinemia (WM). The approval was based on results of a study in WM patients that showed overall response rate (ORR) of 91% and median time to response of 4 weeks. Temporary interruption of ibrutinib is sometimes needed to manage toxicities or perioperatively to minimize bleeding. Some WM patients developed withdrawal symptoms (fever, body aches, night sweats, arthralgias, chills, headache, fatigue) while holding ibrutinib, which then resolved promptly after ibrutinib reinitiation. A retrospective study shows that withdrawal symptoms develop in 20% of WM patients who hold ibrutinib therapy. The rate of withdrawal symptoms was lower in patients who started ibrutinib at serum IgM levels ≥4,000 mg/dl and CXCR4 mutated patients, and higher in patients who had achieved a very good partial response (VGPR) on ibrutinib. Symptoms ensue within 2 days of ibrutinib hold and resolve rapidly following reinitiation of therapy. In two thirds of the patients who experience withdrawal, there is no evidence of disease progression during ibrutinib hold. In the patients who progress during the hold, response is regained within 3 months of ibrutinib reinitiation.

Ibrutinib discontinuation in Waldenström macroglobulinemia: Etiologies, outcomes, and IgM rebound. Gustine JN, Meid K, Dubeau T, Severns P, Hunter ZR, Guang Y, Xu L, Treon SP, Castillo JJ.  American J. Hematol. 2018;93:511–517. doi.org/10.1002/ajh.25023. This is a retrospective review of patients with WM who discontinued ibrutinib and their subsequent outcomes. Reasons for discontinuation include: disease progression, toxicity, non-response, and other unrelated reasons. A baseline platelet count ≤100 K/µL and presence of tumor CXCR4 mutations were independently associated with 4‐fold increased odds of ibrutinib discontinuation. An IgM rebound (≥25% increase in serum IgM) was observed in (73%) following ibrutinib discontinuation and occurred within 4 weeks for nearly half of patients. The response rate to salvage therapy was 71%; responses were higher in patients without an IgM rebound and when salvage therapy was initiated within 2 weeks of stopping ibrutinib. Patients who discontinued ibrutinib due to disease progression versus nonprogression events had significantly shorter overall survival. Response to salvage therapy was associated with an 82% reduction in the risk of death following ibrutinib discontinuation. WM patients who discontinue ibrutinib require close monitoring, and continuation of ibrutinib until the next therapy should be considered to maintain disease control.

Phase I study of an active immunotherapy for asymptomatic phase lymphoplasmacytic lymphoma with DNA vaccines encoding antigen-chemokine fusion: study protocol. Thomas SK, Cha S, Smith DL, Kim KH, Parshottam SR, Rao S, Popescu M, Lee VY, Neelapu SS, Kwak LW. BMC Cancer 2018 18:187 doi.org/10.1186/s12885-018-4094-2. There is now a renewed interest in cancer vaccines. Patients responding to immune checkpoint blockade usually bear tumors that are heavily infiltrated by T cells and express a high load of neoantigens, indicating that the immune system is involved in the therapeutic effect of these agents; this finding strongly supports the use of cancer vaccine strategies. Asymptomatic patients with lymphoplasmacytic lymphoma (LPL) are currently managed by a “watchful waiting” approach, as available therapies provide no survival advantage if started before symptoms develop. Tumor-specific markers and effective vaccination was demonstrated in a positive controlled phase III trial for LPL patients. This vaccine could shift the current paradigm of clinical management for patients with asymptomatic LPL and aid the development of other personalized approaches.

Long-term follow-up of monoclonal gammopathy of undetermined significance. Kyle RA, Larson DR, Therneau TM, et al., N Engl J Med 2018: 378:241-249.
MGUS affects more than 5% of persons older than seventy years and shortens survival, as compared to age-matched controls. In a long term study involving more than 1000 patients, those with IgM GUS had a higher rate of progression to B-cell cancer than those with IgG MUS.

Ibrutinib-associated bleeding: pathogenesis, management, and risk reduction strategies. Shatzel KK, Olson SR, Tao DL, McCarty OJT, Danilov AV, DeLoughery TG. J Thromb Haemost 2017, 15: 835-47. Ibrutinib is an irreversible inhibitor of Bruton’s tyrosine kinase (BTK) that has proven to be an effective therapeutic agent for multiple B-cell-mediated lymphoproliferative disorders, including WM. Ibrutinib carries an increased bleeding risk compared with standard chemotherapy. This can range from minor bleeding to life-threatening hemorrhage.  In this review, the authors caution against using non-steroidal anti-inflammatory drugs, fish oils, vitamin E, and aspirin containing products, vitamin K antagonists, among other risk reduction strategies.

How I manage monoclonal gammopathy of undetermined significance. Go, RS, Rajkumar SV.  Blood 2018 131:163-173; doi.org/10.1182/blood-2017-09-807560 Monoclonal gammopathy of underdetermined significance (MGUS) is, in many ways a unique hematologic entity. MGUS is considered an obligate precursor to several lymphoplastic malignancies, including immunoglobulin light-chain amyloidoisis, multiple myeloma, and Waldenstrom macroglobulinemia. The authors present 7 vignettes to illustrate common clinical management questions that arise during the course of MGUS. They describe how they practice provide a rationale for their approach. They also discuss the potential harms associated with MGUS diagnosis, a topic rarely broached between patients and providers.

Serum IgM level as predictor of symptomatic hyperviscosity in patients with Waldenstrom macroglobulinaemia. Gustine JN, Meid K, Dubeau T, Hunter ZR, Xu L, Yang G, Ghobrial IM, Treon SP and Castillo JJ. British Journal of Haematology, 2017, 177, 717–725; DOI: 10.1111/bjh.14743. Symptomatic hyperviscosity is a common clinical manifestation in patients with Waldenstrom macroglobulinaemia (WM) and high serum IgM levels. Prompt intervention is required to prevent catastrophic events, such as retinal or central nervous system bleeding. Identifying patients at high risk of symptomatic hyperviscosity might support the decision to treat asymptomatic patients before irreversible damage occurs. A large retrospective study showed the odds of developing symptomatic hyperviscosity were 370-fold higher with serum IgM levels >60 g/l, and showed an association with CXCR4 mutational status. Symptomatic hyperviscosity did not impact overall survival. The findings support the use of serum IgM level >60 g/l as a criterion for initiation of therapy in an otherwise asymptomatic WM patient.

Diagnosis and Management of Waldenström Macroglobulinemia Mayo Stratification of Macroglobulinemia and Risk-Adapted Therapy (mSMART) Guidelines 2016. Kapoor P, Ansell SM, Fonseca R, et al. JAMA Oncol.2017;3(9):1257–1265. i:10.1001/jamaoncol.2016.5763. The Mayo Clinic Cancer Center Myeloma, Amyloidosis and Dysproteinemia and Lymphoma Disease-Oriented Groups have updated their evidence-based recommendations for the management of WM. Important advances have led to a broader understanding of the biology of WM since their initial risk stratification–based approach was published in 2010. Clinical and observational studies published or presented through December 2015 are reviewed to provide consensus recommendations for clinicians. The guidelines are formulated using a grading system of evidence and grades of recommendations

Safety and efficacy of selinexor in relapsed or refractory multiple myeloma and WM. Chen C, Siegel D, Gutierrez M, et al, Blood, 2017, doi:10.1182/blood-2017-08-797886. The XPO1 inhibitor selinexor is an oral agent with a completely novel mechanism of action and anti-MM/WM activity in combination with dexamethasone that could provide a new option for patients with relapsed or refractory disease.

Acquired mutations associated with ibrutinib resistance in Waldenstrom macroglobulinemia. Xu L, Tsakmaklis N, Yang G, Chen JG, Liu X, Demos M, Kofides A, Patterson CJ, Meid K, Gustine J, Dubeau T, Palomba ML, Advani R, Castillo JJ, Furman RR, Hunter ZR, Treon SP,Blood 2017 129:2519-2525; doi.org/10.1182/blood-2017-01-761726  Ibrutinib produces high response rates and durable remissions in Waldenstrom macroglobulinemia (WM) that are impacted by MYD88 and CXCR4WHIM mutations. Disease progression can develop on ibrutinib, although the molecular basis remains to be clarified. This study showed that Bruton tyrosine kinase (BTK) mutations are common in WM patients with clinical disease progression while on ibrutinib, and are associated with mutated CXCR4.

New developments in the management of Waldenstrom macroglobulinemia. Abeykoon, J. P., Yanamandra, U., & Kapoor, P. (2017), Cancer Management and Research, 9, 73–83. doi.org/10.2147/CMAR.S94059 The management of WM is evolving, with a deeper understanding of the disease pathophysiology and introduction of new drugs. In this excellent review article, the authors discuss new developments in the management of WM based on data published over the past 15 years, with an emphasis on the role of Bruton's tyrosine kinase (BTK) inhibitor, ibrutinib.

Once-weekly ofatumumab in untreated or relapsed Waldenström’s macroglobulinaemia: an open-label, single-arm, phase 2 study. Furman RR, Eradat HA, DiRienzo CG, Hofmeister CC, Hayman SR, Leonard JP, Coleman M, Advani R, Chanan-Khan A, Switzky J, Liao QM, Shah D, Jewell RC, Lisby S,and Lin TS, Lancet Haematol 2017; 4: e24–3, dx.doi.org/10.1016/S2352-3026(16)30166-1. The aim of the study was to assess the safety and clinical activity of intravenous ofatumumab monotherapy for untreated and relapsed Waldenström’s macroglobulinaemia. They found a high proportion of patients achieved an overall response with ofatumumab as a single therapy and this treatment was well tolerated, with a low incidence of IgM flare. This therapy might be a non-chemotherapeutic treatment option for patients with Waldenström’s macroglobulinaemia, especially those with high IgM concentrations.

How I treat cryoglobulinemia. Muchtar E, Magen H and Gertz MA, Blood. 2017;129(3):289-298. Cryoglobulinemia is a distinct entity characterized by the presence of cryoglobulins in the serum. Cryoglobulins differ in their composition, which has an impact on the clinical presentation and the underlying disease that triggers cryoglobulin formation. Found in some patients with Waldenstrom’s macroglobulinemia, the authors explore the spectrum of this heterogeneous disease by discussing the disease characteristics of 5 different patients, including one with WM.

Dexamethasone, rituximab and cyclophosphamide for relapsed and/or refractory and treatment-naïve patients with Waldenström macroglobulinaemia. Paludo J, Abeykoon JP, Kumar S, et al.  Br J Haematol. 2017 Aug 8. doi: 10.1111/bjh.14826. The management of Waldenstrom macroglobulinaemia (WM) relies predominantly on small trials, one of which has demonstrated activity of dexamethasone, rituximab, and cyclophosphamide (DRC) as upfront treatment . The authors report on the efficacy of DRC, focusing on relapsed/refractory patients. Ibrutinib, a recently approved agent in WM demonstrated limited activity in patients with MYD88WT genotype. They additionally report on the activity of DRC based on the MYD88L265P mutation status. They conclude that in contrast to ibrutinib, DRC offers a less expensive, fixed-duration option, with preliminary data suggesting efficacy independent of the patients' MYD88 status.

Waldenstrom's Macroglobulinemia. 1st ed, Leblond V, Treon S, Dimoploulos M (eds.), Springer International Publishing, Switzerland. 2017. With the  participation of many widely-recognized experts, this comprehensive book sheds new light on clinical, biological, and therapeutic data on Waldenstrom's macroglobulinemia. The book is divided into seven parts; tumor cells and microenvironment, epidemiology and genetic predisposition, clinical features, laboratory investigations, response, prognostic factors, and treatment options and recommendations.

Serum IgM level as predictor of symptomatic hyperviscosity in patients with Waldenstrom macroglobulinemia. Gustine, J. N., Meid, K., Dubeau, T., Hunter, Z. R., Xu, L., Yang, G., Ghobrial, I. M., Treon, S. P. and Castillo, J. J. (2017), Br J Haematol, 177: 717–725. doi:10.1111/bjh.14743. Symptomatic hyperviscosity is a common clinical manifestation in patients with Waldenstrom macroglobulinemia (WM) and high serum IgM levels. Prompt intervention is required to prevent catastrophic events, such as retinal or central nervous system bleeding. Identifying patients at high risk of symptomatic hyperviscosity might support the decision to treat asymptomatic patients before irreversible damage occurs. They carried out a large retrospective study in newly diagnosed WM patients, Their findings support the use of serum IgM level >60 g/l as a criterion for initiation of therapy in an otherwise asymptomatic WM patient.

Investigation and management of IgM and Waldenström-associated peripheral neuropathies: recommendations from the IWWM-8 consensus panel. D'Sa, S., Kersten, M. J., Castillo, J. J., Dimopoulos, M., Kastritis, E., Laane, E., Leblond, V., Merlini, G., Treon, S. P., Vos, J. M. and Lunn, M. P. (2017), Br J Haematol. doi:10.1111/bjh.14492
The International Workshops on Waldenström Macroglobulinaemia (IWWM) have proposed criteria for diagnosis and therapy (Owen et al, 2003), response (Owen et al, 2013), and treatment (Dimopoulos et al, 2014) in WM patients. As part of its latest consensus deliberations (IWWM8, London 2014), the panel reviewed the management of peripheral neuropathies associated with IgM monoclonal gammopathies, including WM.  Importantly, a consensus regarding the use of clinical outcome measures and recommended models of care for this group of patients is discussed, as well as appropriate treatment interventions.

Genomics, Signaling, and Treatment of Waldenström Macroglobulinemia. Zachary R. Hunter, Guang Yang, Lian Xu, Xia Liu, Jorge J. Castillo, and Steven P. Treon Journal of Clinical Oncology  2017, 35(9):994-1001. Next-generation sequencing studies have identified highly recurrent somatic mutations in MYD88, CXCR4, ARID1A, and CD79, and other genes, as well as copy number alterations effecting important regulatory genes in chromosome 6q and elsewhere. Transcriptional changes, disease presentation, therapeutic outcome, and overall survival are affected by mutations in MYD88 and/or CXCR4. (Article provided with permission of the Bing Center for Waldenstrom's Macroglobulinemia.)

Ibrutinib for patients with rituximab-refractory Waldenström's macroglobulinaemia (iNNOVATE): an open-label substudy of an international, multicentre, phase 3 trial. Dimopoulos, Meletios A et al. The Lancet Oncology, 2017,18(2):241 - 250. In the era of widespread rituximab use for Waldenström's macroglobulinaemia, new treatment options for patients with rituximab-refractory disease are an important clinical need. Ibrutinib has induced durable responses in previously treated patients with Waldenström's macroglobulinaemia. This study assessed the efficacy and safety of ibrutinib in a population with rituximab-refractory disease. (Article provided with permission of the Bing Center for Waldenstrom's Macroglobulinemia.)

Waldenstrom Macroglobulinemia: 2017 Update on Diagnosis, Risk Stratification, and management. Gertz, MA, Am. J. Hematol. 92:209–217, 2017. This Mayo Clinic clinician provides a technical clinical update of WM, as part of the Annual Clinical Updates in Hematological Malignancies Series from the American Journal of Hematology.

Guidelines for the diagnosis, treatment and response criteria for Bing-Neel syndrome. Minnema  MC. et al. Haematologica, 2017 Volume 102(1):43-51 obtained from the Haematologica Journal website. Bing Neel syndrome is a rare disease manifestation of Waldenstrom’s macroglobulinemia that results from infiltration of the central nervous system by malignant lymphoplasmacytic cells. These technical guidelines describe the clinical symptoms, as well as, the appropriate laboratory and radiological studies that can aid in the diagnosis. A discussion of prospective clinical trials and protocols that employ uniform treatment for delineating treatment outcomes is included.

Prospective, multicenter clinical trial of everolimus as primary therapy in Waldenstrom macroglobulinemia (WMCTG 09-214). Treon SP, Meid K, Christina Tripsas C, Heffner L, Eradat H, Badros AZ, Xu L, Hunter ZR, Yang G, Patterson CJ, Gustine J, Castillo JJ,  Matous J, Ghobrial IM. Blood Dec. 2016 128(22):4487. Everolimus inhibits mTOR, a component of PI3K/AKT pro-survival signaling triggered by MYD88 and CXCR4 activating mutations in Waldenstrom’s Macroglobulinemia (WM). They evaluated everolimus in a prospective, multicenter study of symptomatic, previously untreated WM patients. They found that everolimus is active in previously untreated WM. Serum IgM discordance with bone marrow disease burden was common and treatment cessation often lead to rapid serum IgM rebound. Pneumonitis also appeared more pronounced in untreated versus previously treated WM patients. They concluded that risks and benefits of everolimus should be carefully weighed against other primary WM therapy options.

Treatment Recommendations for Waldenström Macroglobulinemia from the Eighth International Workshop on WM. Leblond, V., et al. Blood, September 8, 2016, Volume 128, Number 10. These are updated treatment recommendations from the August 2014 International Workshop in London, England. (Article provided with permission of Dr. Steven Treon of the Bing Center for Waldenstrom's Macroglobulinemia.)

Paraproteinemic neuropathy: a practical review.  Rison RA, Beydoun SR, BMC Neurology 2016 16:13 doi.org/10.1186/s12883-016-0532-4 The term paraproteinemic neuropathy describes a heterogeneous set of neuropathies characterized by the presence of homogeneous immunoglobulin in the serum. An abnormal clonal proliferation of B-lymphocytes or plasma cells produces the immunoglobulins in excess. In this review, the authors provide a clinically practical approach to diagnosis and management of patients with this condition.

Future therapeutic options for Waldenstrom macroglobulinemia. Castillo JJ, Hunter ZR, Yang G, Argyropoulos K, Palomba ML, Treon SP. Best Practice & Research Clinical Haematology 29 (2016) 206-215. This review focuses on potential therapies that could change the landscape of treatment of patients with WM, specifically focusing on inhibitors 

Waldenström's Macroglobulinemia: Subtype Review. Lymphoma Coalition, August 2016. This is an overview of the disease prepared by the Lymphoma Coalition with review and editing assistance provided by the IWMF. It covers the basic biology of WM, along with current treatment recommendations from NCCN and from Dr. Steven Treon of the Bing Center for WM. Special sections of this report look at treatment availability and clinical trial activity in multiple countries and discuss the patient experience in terms of physical symptoms and psychological and social factors that impact the patient's sense of well being.

Waldenstrom macroglobulinemia: biology, genetics, and therapy. Paludo J, Ansell SM, Blood and Lymphatic Cancer: Targets and Therapy, 2016, 6:49-58. An excellent review that covers the pathophysiologic understanding of WM in light of the discovery of MYD88 and CXCR4, as well as treatment regimens with a focus on ibrutinib.

Recommendations for the diagnosis and initial evaluation of patients with Waldenström Macroglobulinaemia: A Task Force from the 8th International Workshop on Waldenström Macroglobulinaemia. Jorge J. Castillo et al, British Journal of Haematology, 2016. A multi-institutional task force was formed during the 8th International Workshop for WM in London to develop consensus recommendations for the diagnosis and initial evaluation of patients with WM. In this document, recommendations are provided for history-taking and physical examination, laboratory studies, bone marrow aspiration and biopsy analysis, and imaging studies. Guidance is also provided on the initial evaluation of special situations, such as anemia, hyperviscosity, neuropathy, Bing-Neel syndrome, and amyloidosis. (Article provided with permission of Jorge J. Castillo of the Bing Center for Waldenstrom's Macroglobulinemia.)

How I Treat Waldenstrom Macroglobulinemia. Treon, S. P., Blood. First Edition Paper, prepublished online May 22, 2015, DOI 10.1182. Treatment recommendations published by Dr. Steven Treon of the Dana-Farber Cancer Institute in 2015. (Article provided with permission of the Bing Center for Waldenstrom's Macroglobulinemia.)

Biology, Prognosis, and Therapy of Waldenstrom Macroglobulinemia. Castillo JJ, Ghobrial IM, Treon SP,  in Non-Hodgkin Lymphoma, Cancer Treatment and Research 165, Springer International Publishing, Switzerland, 2015, A.M. Evens and K.A. Blum (eds.), DOI 10.1007/978-3-319-13150-4_7. In this chapter, the authors review the recent advances in the biology of WM and the current therapeutic options for untreated and relapsed WM patients. They also discuss the role of prognostic factors and current evidence supporting an improvement in the survival of WM patients in the last decade.

NCCN Clinical Practice Guidelines in Oncology for Macroglobulinemia/Lymphoplasmacytic Lymphoma. The NCCN is a non-profit alliance of 27 cancer centers in the U.S. whose goal is to improve the quality and effectiveness of care provided to cancer patients. They provide updated guidelines based on the most current and up-to-date diagnosis and treatment guidelines available. You must establish an account on the NCCN website to login and view these guidelines.

Systemic Light Chain Amyloidosis: an update for treating physicians. Merlini G, Wechalekar AD, Palladini G, Blood. 2013;121(26):5124-5130. In immunoglobulin light chain amyloidosis a small, indolent plasma cell clone synthesizes light chains that cause devastating organ damage. Early diagnosis, based on prompt recognition of “red-flags” before advanced cardiomyopathy ensues, is essential for improving outcomes, such as recovery of organ function and prolonged survival.

MYD88 L265P Somatic Mutation in Waldenström’s Macroglobulinemia. Steven P. Treon et al, Dana-Farber Cancer Institute, Boston MA. This article, published in the New England Journal of Medicine in 2012, outlines the seminal discovery of the prevalence of the MYD88 L265 P mutation in WM patients. The research leading to this discovery was funded in part with the support of the IWMF.

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