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Amyloid Deposits in the Bone Marrow of Patients withImmunoglobulin Light Chain Amyloidosis Do NotImpact Stem Cell Mobilization or Engraftment

Andrew J. Cowan,1 David C. Seldin,1,2 Martha Skinner,1 Karen Quillen,2,3 Gheorghe Doros,1,4

Josenia Tan,3 Carl O’Hara,1,3 Kathleen T. Finn,1,2 Vaishali Sanchorawala1,2

Amyloid deposits are often found in the bone marrow in patients with Immunoglobulin light chain (AL)amyloidosis. We sought to determine whether this affects stem cell collection or engraftment after high-dose melphalan and autologous stem cell transplantation (HDM-SCT). We reviewed data on 361 patientswith AL amyloidosis who had Congo red staining of pretreatment bone marrow biopsy specimens and un-derwent HDM-SCT between July 1994 and December 2011. We analyzed data on stem cell yield, days ofstem cell collection, and days to neutrophil and platelet engraftment posttransplantation. Bone marrow am-yloid deposits were found in 65% of patients (n5 233). There were no significant differences in median num-ber of stem cells collected and days to neutrophil or platelet engraftment between patients with bonemarrow amyloid deposits and those without these deposits. Thus, our data indicate that although amyloidinvolvement of the bonemarrow is common, it does not negatively affect stem cell mobilization or neutrophiland platelet engraftment after HDM-SCT.

Biol Blood Marrow Transplant 18: 1935-1938 (2012) � 2012 American Society for Blood and Marrow Transplantation

KEY WORDS: Melphalan, Stem cell collection, Stem

cell transplantation

INTRODUCTION

High-dose melphalan (HDM) and autologousstem cell transplantation (SCT) is an important treat-ment modality for selected patients with immunoglob-ulin light chain (AL) amyloidosis [1]; however,typically fewer than one-half of newly diagnosed pa-tients are eligible for this treatment [2]. SCT is usedsuccessfully in treatment of multiple hematologic dis-orders and some solid tumors. A rare complication is

1Amyloid Treatment and Research Program, Boston Uni-y School of Medicine, Boston, Massachusetts; 2Stem Cellplantation Program, Section of Hematology-Oncology,tment of Medicine, Boston Medical Center, Boston,chusetts; 3Department of Pathology and Laboratoryine; and 4Department of Biostatistics, Boston Universityl of Public Health, Boston, Massachusetts.isclosure: See Acknowledgments on page 1938.dence and reprint requests: Vaishali Sanchorawala, MD,n Medical Center, Section of Hematology-Oncology,1007, 820 Harrison Avenue, Boston MA 02118 (e-mail:li.sanchorawala@bmc.org).une 25, 2012; accepted July 19, 2012erican Society for Blood and Marrow Transplantation/$36.00oi.org/10.1016/j.bbmt.2012.07.016

primary graft failure, which was reported in 4.7% ofa recent series of 300 patients undergoing SCT [3].Variables associated with favorable engraftmentkinetics include CD341 stem cell dose, as esta-blished by multiple transplantation studies [4-6]. Pre-vious studies have also demonstrated that exten-sive antecedent exposure to alkylating agents nega-tively impacts platelet engraftment [6,7]. A study ofSCT in patients with AL amyloidosis identifiedCD341 stem cell dose, female sex, and previous alky-lator therapy as important variables affecting stemcell engraftment [8].

Amyloid deposition in the bone marrow (BM) iscommon in patients with AL amyloidosis, documentedin 60% of biopsy specimens in a series of 100 patients[9]. Two distinct histological patterns of BM amyloiddeposition have been identified: vascular and intersti-tial. Here we report on the impact of amyloid depositsin the BM on stem cell mobilization and engraftmentkinetics in patients with AL amyloidosis who under-went HDM-SCT.

METHODS

We conducted a retrospective review of data re-corded between July 1994 and December 2011 in

1935

Table 1. Patient Characteristics

BM AmyloidDeposits(n 5 233)

Interstitial BMAmyloid(n 5 83)

No BMAmyloid(n 5 128)

P Value, Amyloidversus

No Amyloid

P Value, InterstitialAmyloid versusNo Amyloid

Age, years, median (range) 56 (28-80) 56 (28-71) 57 (35-79) .88 .07Female sex, n (%) 91 (39) 34 (41) 51 (40) .88 .87Clonality, n (%)

Kappa 51 (22) 25 (30) 20 (16) .15 .01Lambda 182 (78) 58 (70) 108 (84) .15 .01

Organ involvement, n (%)Renal 221 (95) 77 (93) 95 (74) <.001 <.001Cardiac 109 (47) 34 (41) 59 (46) .90 .46Hepatic 77 (33) 49 (59) 20 (16) <.001 <.001Soft tissue 50 (21) 16 (19) 39 (30) .06 .07Gastrointestinal 53 (23) 20 (24) 18 (14) .05 .06Autonomic nervous system 68 (29) 21 (25) 21 (16) .01 .11Peripheral nervous system 25 (11) 5 (6) 13 (10) .87 .29Pulmonary 14 (6) 7 (8) 6 (5) .60 .27More than 2 organs involved 116 (50) 45 (54) 41 (32) .001 .001

Baseline laboratory valuesSerum creatinine, mg/dL 1.1 (0.4-14.8) 1.2 (0.5-11.7) 0.9 (0.4-13.3) .80 .6624-hour urine protein, mg 5875 (<60-58,212) 5797 (<60-27,456) 3629 (<60-20,493) .09 .004Bone marrow plasma cells, % 5 (5-25) 5 (5-25) 10 (<5-30) .06 .28

Previous treatment, n (%)Alkylator-based treatments 54 (23) 21 (25) 21 (16) .06 .049Immunomodulatory drug-based treatments 3 (1) 0 (0) 6 (5) .06 .049

igure 1. Extensive interstitial amyloid deposition in a patient withL amyloidosis, with almost total replacement of the BM. Amyloid isighlighted by periodic acid-Schiff and Congo red stains.

1936 Biol Blood Marrow Transplant 18:1935-1944, 2012A. J. Cowan et al.

Boston University’s Amyloid Treatment and ResearchProgram database. Patients with AL amyloidosis whounderwent HDM-SCT at this institution and haddocumented Congo red staining performed on theinitial BM biopsy specimen were included in our anal-ysis. Patients who initiated stem cell mobilization butdid not proceed to HDM owing to either death orcomplications were excluded. Patients who completeda course of HDM but died before platelet or neutro-phil engraftment were included in the overall analysisbut were excluded from the analysis of engraftmentkinetics.

Data were collected on baseline demographics,laboratory test results, organ involvement, and previ-ous treatment. Baseline data were collected on quanti-tative serum free light chain assay and BM plasma cellpercentage, and the difference in involved free lightchain and uninvolved free light chain (dFLC) was cal-culated. Data on stem cell collection yield, number ofdays of collection, and days to neutrophil and plateletengraftment posttransplantation were collected andanalyzed.

Amyloid deposits in BM biopsy specimens stainedwith Congo red were graded as 0 (absent), 11 (vascu-lar only), 21 (limited interstitial deposits, \2/high-power field), or 31 (extensive interstitial deposits,.2/high-power field). Neutrophil engraftment wasdefined as an absolute neutrophil count of .500cells/mL for 2 consecutive days, and platelet engraft-ment was defined as a platelet count .20,000/mLwithout platelet transfusion during the previous 48hours.

Descriptive statistics were used to summarize pa-tient characteristics. c2 tests were used for comparingproportions, and t tests were used for comparingmeans. A P value#.05 was considered statistically sig-nificant. All statistical analyses were performed usingSAS version 9.2 (SAS Institute, Cary, NC).

RESULTS AND DISCUSSION

Patient Characteristics

A total of 361 patients with AL amyloidosis anddocumented Congo red staining of initial BM biopsyspecimens underwent HDM-SCT (Table 1). The

FAh

Table 2. Stem Cell Collection and Engraftment Data

BM AmyloidDeposits(n 5 233)

Interstitial BMAmyloid(n 5 83)

No BM AmyloidDeposits(n 5 128)

P Value,Amyloid versusNo Amyloid

P Value, InterstitialAmyloid versusNo Amyloid

CD34+ cells collected, �106, median (range) 6.8 (0.2-31.4) 7.23 (0.6-24.1) 6.9 (0.28-20.4) .988 .79Number of collections, mean (range) 2 (0.5-5) 2 (1-4) 2 (1-4) .444 .132Time to neutrophil engraftment, days, median (range) 10 (5-16) 10 (5-16) 10 (8-17) .691 .213Time to platelet engraftment, days, median (range) 13 (7-93) 13 (7-32) 12 (8-46) .177 .79

Biol Blood Marrow Transplant 18:1935-1944, 2012 1937Amyloid Deposits in Bone Marrow in AL Amyloidosis

majority of patients (233; 65%) had evidence of BMamyloid deposition; 150 of these 233 patients (64%)had vascular amyloid deposition only (11), 27 hadlimited interstitial amyloid deposition (12%), and56 (24%) had extensive interstitial amyloid deposition(Figure 1). All together, 83 patients (36%) had intersti-tial amyloid deposition, and 128 patients (35%) had noamyloid deposition.

Clonality was more frequently lambda than kappain all groups. Kappa predominance was detected in 25patients (30%) with interstitial amyloid deposition(30%), compared with 20 patients without BM amy-loid deposition (16%) (P 5 .01).

Organ involvement differed among the studygroups. Coexistent renal involvement was present in221 patients (95%) with BM amyloid deposition, com-pared with 95 patients (74%) without BM amyloid de-position (P \ .001). Multiorgan involvement (morethan 2 organs) was found in 116 patients (50%) withamyloid BMdeposition and in 54% of patients with in-terstitial amyloid (54%), compared with 41 (32%) ofthose without BM amyloid deposition (P 5 .001 forboth comparisons).

Fifty-four patients (23%) with BM amyloid de-position had received previous treatment beforeHDM-SCT, compared with 21 patients (16%) with-out BM amyloid deposition, an insignificant difference(P 5 .06).

Stem Cell Mobilization, Collection, andEngraftment

In all patients, the stem cell mobilization regi-men included granulocyte colony-stimulating factor10-16 mg/kg/day for 3-4 days. The median numberof stem cells collected was 6.8 � 106 CD341

cells/kg (range, 0.2-31.4 � 106 CD341 cells/kg) inall patients with BM amyloid deposition (both vas-cular and interstitial) and 7.2 � 106 CD341 cells/kg (range, 0.6-24.1 � 106 CD341 cells/kg) in pa-tients with interstitial amyloid (Table 2). In patientswithout BM amyloid deposition, median stem cellcollection was 6.9 � 106 CD341 cells/kg (range,0.28-20.4 � 106 CD341 cells/kg). This value wasnot statistically significantly different from that ineither all patients with BM amyloid deposits orthose with only interstitial amyloid deposits

(P 5 .79). A mean of 2 collections was required inall groups.

In the total cohort, 8 patients died before neutro-phil engraftment, and 10 additional patients died be-fore platelet engraftment. These patients wereexcluded from engraftment analyses. The mediantime to neutrophil engraftment was 10 days (range,5-16 days) in all patients with BM amyloid depositionand those with interstitial BM amyloid depositiononly, and 10 days (range, 8-17 days) in patients withoutBM amyloid deposition. There were no significant dif-ferences among these groups (P 5 .691 and .213,respectively).

The median time to platelet engraftment was13 days (range, 7-93 days) in patients with BM amyloiddeposition, 13 days (range, 7-32 days) in patients withinterstitial BM amyloid deposition, and 12 days (range,8-46 days) in patients without BM amyloid deposition.There were no significant differences among thesegroups (P 5 .177 and .79, respectively).

Thirty-eight patients (11%) experienced mobiliza-tion failure, defined as collection of\2.5� 106CD341

cells/kg.However, thesepatients did proceed toHDM-SCT after undergoing BM harvest. The proportion offailures was not significantly different between allpatients with BM amyloid deposition and the subgroupwith extensive amyloid deposition (P 5 .15 and 1.0,respectively). No significant differences in BM harvestwere observed among these groups (P 5 .23 and 1.0,respectively). Notably, 22 (58%) of these patientsreceived pretreatment, the majority (95%) with oralmelphalan.

BM amyloid deposition was relatively common inour series of 361 patients with AL amyloidosis whounderwent HDM-SCT, occurring in 65% of pa-tients. Theoretically, given the potential extensive na-ture of amyloid BM deposition, this could impedestem cell collection and engraftment after HDM-SCT. Nonetheless, neither vascular nor more exten-sive interstitial BM amyloid deposition had any neg-ative impact on stem cell mobilization, stem cellcollection, or neutrophil and platelet engraftment ki-netics. Indeed, our engraftment data are similar topreviously published posttransplantation stem cellengraftment data in these patients [8], but the num-bers here are much larger and encompass more yearsof study.

1938 Biol Blood Marrow Transplant 18:1935-1944, 2012A. J. Cowan et al.

In keeping with previous findings from our institu-tion, kappa clonality was more common in patientswith BM amyloid deposition than in those withoutthis deposition [9]. The association of amyloid BMdeposition and greater renal and multiorgan involve-ment merits further investigation.

ACKNOWLEDGMENTS

We acknowledge the participation of colleaguesin the Amyloid Treatment and Research Programat Boston University School of Medicine and theStem Cell Transplant Program at Boston MedicalCenter.

Authorship Statement: Andrew J. Cowan, David C.Seldin, Martha Skinner, and Vaishali Sanchorawaladesigned the study; Josenia Tan and Carl O’Haraperformed pathological analysis of the bone marrowspecimens; Gheorghe Doros performed statisticalanalysis; Andrew J. Cowan and Vaishali Sanchora-wala analyzed the data and wrote the manuscript;David C. Seldin, Martha Skinner, Karen Quillen,and Kathleen T. Finn critically reviewed the manu-script; and all authors approved the final version ofthe manuscript.

Financial disclosure: The development of the Am-yloid Repository and Database was supported by Na-tional Institutes of Health grant P01 HL68705 andby grants from the Gruss and Wildflower Founda-tions. The authors have no conflicts of interest todisclose.

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