Slide 1

Good morning. I want first to thank the organisers for inviting me to speak about this severe and complicated disease. I am a clinical haematologist in Limoges in France and I am in charge with my nephrologist colleagues from Poitiers, from Bridou and  Guy Touchard of the French National Reference Centre for Primary Amyloidosis.

Slide 2

Amyloidosis is a disease of protein misfolding, proteins that are normally soluble are transformed by the conversion of the tertiary structure into predominantly anti-parallel β sheets secondary structure, into insoluble fibrils resembling silk cables with 3 to 6 filaments one upon another deposit, fibrils which are deposited in the extracellular space of organs and tissues resulting in clinical disease.

Slide 3

Amyloid may affect almost any tissue in the body other than the brain.

Slide 4

The heart, kidneys, tongue, gut, nerves, skin, liver and spleen, lung and muscles are frequently involved. So, the distribution of amyloid varies greatly from patient to patient presenting clinical features of protein and non-specific complaints of malaise, fatigue and weight loss are common.

Slide 5

Amyloid is a generic term and includes as well as light chain deposits,  AL or primary amyloidosis that is the subject of this talk but also AA amyloidosis due to chronic inflammation. β2 amyloidosis seen in dialysis, senile amyloidosis and inherited forms which include transthyretin, a poly (pro) protein, lysozyme and fibrinogen.

Slide 6

These forms are important to know for nephrologists because some can have a dominant renal presentation, particularly those due to fibrinogen mutation. Initial investigations should confirm the diagnosis of amyloidosis and tissue biopsy and this should be followed by investigations to establish the type of amyloid present.

Slide 7

It’s not always easy to be certain that amyloid disease is of AL type because Wright test only differentiates AA and β 2 forms from the others but not AL and inherited and that’s frequently the problem and because tending for immunoglobulin light chains is unreliable without freeze biopsies. The presence of a paraprotein does not per se confirm a diagnosis of AL amyloidosis due to the increasing weight of MGUS with age. In cases of doubt DNA analysis maybe necessary. On the opposite AL amyloidosis can be missed because of underlying monoclonal gammopathies are often very subtle and are not always detectable by conventional techniques.

Slide 8

Electrophoresis has a lower detection limit of 500 mg/L and immunofixation about 150 mg/L. With these techniques monoclonal immunoglobulin is undetectable in 20% of patients and more important unquantifiable in more than 40%.

Slide 9

You have often electrophoresis with a profound hypoalbuminemia in serum without major spike in the urine and with mainly albumin.

Slide 10

It was agreed maybe 6 years ago by Professor Bradwell and binding site to develop a new serum free light chain. You have seen that this test used polyclonal antibodies to hidden light chain determinants. Normal levels in healthy serum are low, 16 mg/l for kappa and 29mg/l for lambda and the sensitivity is excellent and allows to detect free monoclonal light chains in the majority of patients with AL amyloidosis.

Slide 11

Here you see our experience with 65 patients. 95.5% at elevated free light chain level. So you have to be very careful for the diagnosis for AL if FLC are not elevated.

Slide 12

AL-amyloidosis is not a neoplasm per se. Most of the time the patient presents with MGUS or stage I myeloma. The monoclonal protein does not increase over time and the percentage of bone marrow plasma cells is usually low and remains stable over time. Evolution from AL to symptomatic multiple myeloma is very, very rare. Death is due to accumulation of systemic amyloid deposits.

Slide 13

A common false idea is that if there is no overt malignant proliferation, there is no need for treatment. In fact, prognosis depends on the extent and nature of organ involvement by amyloid and not on the disease responsible for the monoclonal component secretion. And even it seems that treatments are more efficient, if there is no plasmocytic dyscrasia detectable in the bone marrow as published recently.

Slide 14

Amyloid deposits exist in a state of dynamic turnover with formation superior to elimination at diagnosis.

Slide 15

The aim of treatment could be to reduce the weight of amyloid formation or to increase elimination and some drugs are experimented. The efficiency of ---, a GAG mimetic to slow renal insufficiency in AL amyloidosis has recently have been published in the New England Journal of Medicine. As a perculator is experimented in the National Amyloid Centre in London and anti-fibril antibodies have been shown to accelerate amyloid elimination in mouse and we are waiting for human experimentation.

Slide 16

For AL amyloidosis the aim for therapy remains to rapidly reduce a supply of amyloid forming monoclonal free light chains by suppressing the underlying plasma cell dyscrasia. The treatment is not directly active on the deposits as it can be in lymphoma or in nodes. Amyloid deposits can be reabsorbed and organ function restored, if the synthesis of the amyloidosic protein precursor is shut down.

Slide 17

Evaluating clinical response is difficult in AL amyloidosis and takes a very long time. A rapid evaluation of therapeutic effect is mandatory due to the very poor prognosis of non-responding patients. Serum FLC assay enables routine quantitative measurements of the fibril precursor protein in 95% of patients with AL amyloidosis and allows early assessment of treatment response.

Slide 18

We have measured using these tests the response in 51 patients. 70% had a decrease of more than 50% of the initial level and that is considered as a good response. 8 of these 36 patients died with a median follow-up of 17 months. 13 of these responding patients had a complete response and no one died. Among the 15 who had no response 12 died.

Slide 19

Here the survival curve according to FLC response. You must obtain a rapid response in this disease, otherwise you lose half of your patients in several months. FLC assay is very important to allow to check this response and to rapidly modify the treatment in case of non-response.

Slide 20

Systemic amyloidosis is a very severe disease. Without an effective treatment, the median survival of patients within 1 month of diagnosis is around 1 year.

Slide 21

In the mid 90s 2 prospective randomised trials definitely demonstrated that a treatment with melphalan and prednisone, the classic MP could prolong survival of AL patients. But improvement in median overall survival with standard alkylator by chemotherapy then it’s 6 months and clinical response rates are only about 20%. Peripheral blood stem cell transplant was introduced as a therapeutic option in the mid 90s and raised hopes because of excellent response rates. Where transplant-related mortality is high and the survival benefits of high dose melphalan has been attributed to a patient selection bias.

Slide 22

So, 8 years ago we considered that a randomised comparison of intensive and conventional treatment was needed to resolve the issue of the respective merits of both therapeutic strategies.

Slide 23

29 centres from the 2 French groups working on myeloma the MAG and the IFM participated in this trial. We entered it to include all patients between 18-70 years old with a biopsy proven AL-amyloidosis with systemic disease and adequate performance status who were able to receive intensive treatment. We only included patients who had not received more than 2 courses of conventional chemotherapy and we did not have symptomatic multiple myeloma.

Slide 24

For randomisation a stratification was done on the basis of age below or over 65 and on the basis of a dominant organ system involvement.

Slide 25

For the intensive arm the procedure was classical in AL-amyloidosis, stem cells were collected after 5 days of G-csf and intensive chemotherapy with 2 and 1 mg/m² of melphalan was given if the number of stem cells collected was sufficient. We reduced the dose of melphalan to 140 mg/ m² in cases of advanced cardiac, renal or hepatic dysfunction and in older patients.

Slide 26

For the conventional arm we tried to improve the result of MP and we reasoned that combining high dose dexamethasone with melphalan could synergise their therapeutic effects and provide more frequent and more rapid hematologic response. So we chose as a conventional treatment M-Dex, melphalan 10 mg/ m² and dexamethasone 40 mg for 4 days each month for up to 18 months.

Slide 27

Not long after the beginning of our study the results of a very similar regimen were reported in Blood by Palladini et al with the response rate much higher than the one done with MP and excellent overall survival.

Slide 28

100 patients were included in our trial between January 2000 and January 2005. 15 each arm. The median age was 58 years with a non-significant difference between the two arms. 19 patients were over 65. The median time from randomisation was 48 days.

Slide 29

The median number of involved organs was 2 from 1-5. Dominant organ system involvement another characteristic was well balanced between the two groups. 47 patients had cardiac involvement and 69 kidney involvement.

Slide 30

Of the 50 randomised in the intensive arm 13 did not receive the planned treatment because the patients were infeasible in one case, because of insufficient numbers of stem cells in two cases and because of disease progression in 10. It is important to note that of the ten deaths that occurred before treatment in this arm 4 occurred during the period of treatment with G-csf. 37 patients completed the procedure. 10 patients received melphalan 140 and 27 melphalan 200. Transplant-related mortality was high it was 24%. The feasibility of M-Dex was good 1% died on day 3 of the first course and the TRM was too constant and 5 patients died before day 100 after the beginning of treatment in most cases from disease progression.

Slide 31

We evaluated hematologic and clinical response in patients who received three or more courses of M-Dex or survived more than 3 months after intensive treatment. We didn’t find any statistically significant difference between the two arms for hematologic or clinic response rate. We observed few relapses. 6 in both arms.

Slide 32

Here is the overall survival curve of the world series. The Kaplan-Meier estimated overall survival is 56.8 months with a median follow-up for living patients of 36 months.

Slide 33

In this trial having a hematologic response complete or partial is a major prognostic factor for survival. This curve shows again the importance of a rapid response assessment best done with free light chain measurement to propose a salvage therapy for refractory patients.

Slide 34

According to arm there is a significant advantage for M-Dex with a median survival of 56 months versus 22 months.

Slide 35

At the time of the point in August 2006 20% had died in the M-Dex arm and 31% in the intensive arm.

Slide 36

The median time between randomisation and initiation of treatment that is first course of M-Dex and dose of G-csf was two and 8 days respectively but median time between randomisation and administration of high dose melphalan was 36 days. The delay before initiation of chemotherapy which was about 1 month longer in the high dose melphalan group than in the M-Dex group, owing to the time required to organise themselves connection and high dose melphalan also contributed along with the toxicity of the high dose treatment to the higher number of early deaths in the HDM group.

Slide 37

Among the 69 patients with renal involvement defined by albuminuria superior to 0.5g/L, the estimated 3-year overall survival rates were 70% and 37% in the M-Dex and high dose melphalan group respectively.

Slide 38

To take into account the possible enrolment of patients with advanced disease resulting in a disadvantage for the high dose melphalan group with 25 of the population in low and high risk patients using the Mayo clinic criteria published in 2001 which takes into account severe cardiac, renal and hepatic involvement. This criterion separates well two groups of patients 41 in the high risk group, mainly with cardiac involvement and 59 in the low risk group mainly with kidney involvement with very different survivals.

Slide 39

Among the low expression were usually considered good candidates for intensive treatment, overall survival at 3 years was 80% in the M-Dex group and 58% in the high dose Melphalan group.

Slide 40

To reduce the influence of early treatment related death on the survival analysis we performed a landmark analysis that included only patients who survived for more than 6 months and who received their allotted treatment. This analysis also showed no advantage for high dose Melphalan over M-Dex.

Slide 41

In conclusion this multicentric study analysed on an intention-to-treat basis showed a clear superiority of M-Dex compared to HDM for AL patients treated in a multicentric setting. These results encourage to recommend M-Dex in first line and to propose HDM only to refractory patients. A comparable trial is ongoing at the Mayo clinic and will conclude on the respective merits of both strategies in a referral centre.

Slide 42

This is an example of excellent response with M-Dex, this 76-year old woman presented 6 years ago with a severe AL amyloidosis with kidney, cardiac, liver and skin involvement. M-Dex obtained a rapid complete response seen on the FLC assay after one course with a rapid clinical improvement.

Slide 43

Proteinuria disappeared in three months which is not usual. Half of patients with renal amyloidosis in complete hematologic response have a 50% decrease in proteinuria after 1 year.

Slide 44

But for high risk patients and non-responding patients new treatments are clearly needed.

Slide 45

One way is to use new drugs active on myeloma. These drugs have been tested in a few trials and have given response rates associated to dexamethasone even in relapsing or refractory patients. The combination of these drugs with alkylating agents seems to be very effective.

Slide 46

The National Amyloid Centre in London has published their results with CTAD, cyclophoshamide, thalidomide and dexamethasone.

Slide 47

With a 74% rate of total response and then excellent survival rates.

Slide 48

I would like to end this talk with a few slides on light and heavy chain deposition disease. There are some differences with AL amyloidosis, the first being an anatomopathological feature. Light chain isotype is more often kappa than in AL amyloidosis. The kidney is almost always involved with rapid renal failure but good recovery if the treatment is successful. Disseminated disease is less frequent than in amyloidosis but symptomatic multiple myeloma is much more frequent.

Slide 49

There are no randomised trials to define the best treatment in this disease. 2 small series on high dose chemotherapy has been published by Royer et al at from ---  hospital in Paris with 11 patients, no toxic death, 8 very good responses and 10 out of 11 patients surviving at a median follow-up of 51 months. By Weichman et al the Boston group with 6 patients, no toxic death, 5 out of 6 patients in complete response and all patients surviving at a median follow-up of 12 months.

Slide 50

Here is an illustrative example of high dose therapy efficacy and usefulness of FLC assay in this disease too. A 46-year old patient was diagnosed in December 1996 with BJ stage 1 myeloma. 5 g/L of proteinuria mainly albumin. The serum creatinine level was 185 μmol/L at diagnosis and the renal biopsy showed a light chain deposition disease. He received an intensive treatment in March 1997 and was considered in complete remission with a normal serum creatinine level for 9 years.

Slide 51

We noticed a progressive rise in kappa FLC over time and a parallel rise in creatinine up to 216. We treated him with velcade dexamethasone and obtained a rapid decrease in FLC and creatinine levels. Then he received a second high dose trying to obtain a durable second remission that probably one cannot obtain with the velcade treatment alone. 

Slide 52

In conclusion in this disease rapid diagnosis and correct typing are absolutely mandatory. FLC dosages are needed for diagnosis and to assess treatment efficacy. M-Dex is the initial treatment of choice but patients who do not respond after 2 or 3 course need alternative treatment. You have to know that after 6 treatments with melphalan dexamethasone it is no longer possible to do cytopheresis to collect stem cells. We are going to begin first two trials with M-Dex associated with novel drugs.

Slide 53

Finally I would like to thank all my colleagues of the participating centres listed here. Thank you for your attention.