Handout for lecture on plasma cell neoplasms presented by Rob McKenna

• The following slides represent a near final version of the presentation that will be given in Maui, January 23,2018. Minor changes in slides and order of slides may appear in the actual lecture.

Issues In Plasma Cell Neoplasms - Focus On WHO-2016 – Presented by Rob McKenna

Notice of Faculty DisclosureIn accordance with ACCME guidelines, any individual in aposition to influence and/or control the content of this CMEactivity has disclosed all relevant financial relationshipswithin the past 12 months with commercial interests thatprovide products and/or services related to the content ofthis CME activity.

The individual below have responded that they have norelevant financial relationship with commercial interest todisclose:

Robert W. McKenna, MD

Plasma Cell Neoplasms (PCN)

• Traditional testing for plasma cell neoplasms

• Role of serum free light chain analysis, immunophenotyping and genetics

• Issues and new criteria in diagnosis of PCN

– Modified criteria for diagnosis of plasma cell myeloma

– Changes in the classification of MGUS

– Issues in diagnosis of solitary plasmacytoma

– Issues in diagnosis of amyloidosis

– Plasma cell neoplasms with a paraneoplastic syndrome

• WHO Classification – 2016

Evaluation for Suspected Plasma Cell Neoplasm

Bone Marrow Aspiration Smears In Plasma Cell Myeloma

IgA Plasma Cell Myeloma Convoluted Plasma Cell myeloma

Plasmablastic Myeloma Cytoplasmic Crystalline Inclusions

Patterns of Marrow Involvement in PCM

Interstitial Focal Diffuse

Lambda

Additional Assessment of PCN

• Serum-free light chain analysis

• Immunophenotype

• Genetics

• Predictive factors (ISS for myeloma)

– Beta 2 microglobulin

– Serum Albumin

– Other

Uses of Serum-Free Light Chain Assay (Quantification and K/L ratio)

• Screening in combination with immunofixation electrophoresis

• Baseline values are prognostic– MGUS– Smoldering myeloma– Symptomatic myeloma– Plasmacytoma– AL amyloidosis

• Hematologic responses to treatment– AL amyloidosis; non-secretory

myeloma;– Stringent complete response in plasma

cell myeloma

Dispenzieri, etal. International Myeloma Working Group guidelines for serum-free light chain analysis in multiple myeloma and related disorders. Leukemia (2009) 23:215-224.

Normal Kappa/Lambda Ratio:0.26 to 1.65

Immunophenotyping Plasma Cell Neoplasms

• Immunohistochemistry

• Flow Cytometry

Kappa

Quantification of Plasma Cells in Plasma Cell Myeloma

Identification of Clonal Plasma Cells

Kappa Lambda

CD138

Differentiating Myeloma From Other Neoplasms

Flow Cytometry Immunophenotyping of Plasma Cell Neoplasms

• Identification of clonal and aberrant plasma cells

• ? Indicator of prognosis

• Detection of minimal residual disease (MRD)

The Immunophenotype of Normal Plasma Cells(Histograms courtesy of Steve Kroft, MD)

Normal Plasma Cells Normal B cells Granulocytes Monocytes

CD38 brightCD19(+) CD20(-)

Polytypic Light Chains

CD45(+)CD56(-)

Flow Cytometry Histograms of Plasma Cell Myeloma

Red = Myeloma plasma cellsBlue = Normal B lymphocytes

Immunophenotype of Plasma Cell Myeloma

CD138+ CD20 (10-20% +)

CD38+ CD56 (65-80% +)

CD79a+ CD117 (30% +)

Clonal CIg+ CD28 (16-48% +)

CD200 (60-75% +)

CD19 (5% +) Cyclin D1 -/+

CD45 (18-75% +) Sig -/+

CD27 (~50% +) CD52 -/+

CD81 (dim/- 95%) CD10 -/+

MRD Matters in Treated PCM

Blood 2008;112:4017-4023

Minimal Residual Myeloma (MRD)-Day 100 Post-Autologous Stem Cell Transplant

Day 100 MRD s/p ASCTAll patients (N=295)

Paiva et al, Blood 2008:4017-4023

58% of patients MRD positive, with median level of 0.14% (range .01-4%)

Myeloma Cells Are Under-Represented in Flow Cytometry Analyses

• 60-70% average decrement compared to aspirate differential count

(Smock etal, Arch Pathol Lab Med 2007;131:951-955; Nadav etal, Br J Haematol 2006;133:530-532; Paiva, Haematologica 2009;94:1599-1602)

• Possible causes:• Hemodilution

• Different distribution of plasma cells in particle-associated and liquid marrow components than other cellular elements

• Loss in processing

Techniques in Genetic Analysis ofPlasma Cell Neoplasms

• Conventional Karyotype Cytogenetics

• Fluorescent In Situ Hybridization (FISH)

• Gene Expression Profiling (GEP)

Conventional Karyotype Cytogenetics

• Standard for detecting genomic abnormalities and outcome discrimination in plasma cell myeloma

• Only ~40% of PCM have identifiable abnormalities

• Deletion of 13 and hypodiploidy are prognostic karyotype changes

• These may not have FISH-defined risk abnormalities

Karyotypes are courtesy of Michelle Dolan, MD, Univ. of MN, Cytogenetic Lab.

Fluorescent In Situ Hybridization (FISH)

• >90% of cases have detectable abnormalities

• Cell sorting or cIg FISH improves yield

• Employed for establishing risk-based stratification

• Ahmann GJ, etal. Cancer Genet. Cytogenet 1998; 101: 7

• Fonseca, R, etal. Cancer Res 2004; 64:1546

• Avet-Loiseau H, etal. Blood 2007; 109: 3489

• Fonseca R, etal. Leukemia 2009; 23:2210

FGFR3 (4p16) / IGH (14q32) 5p15.2 / CEP9 / CEP15

FISH illustrations are courtesy of Michelle Dolan, MD, Univ. of MN Cytogenetics Lab.

Gene Expression Profiling (GEP)

• Powerful technique in patient stratification

• GEP signature distinguishes high- and low-risk myeloma

• Most sensitive and specific for identification of high-risk PCM

References• Zhan F, etal. Blood 2006; 108:2020

(Molecular classification of PCN)

• Shaughnessy JS, etal. Blood 2007; 109:2276 (70 genes linked to high risk—GEP70)

• Chng WJ, etal. Leukemia 2008; 22: 459 (Further validation of GEP70)

• Decaux O, etal. J Clin Oncol 2008; 26:4798 (15 gene model of risk)

• Broyl A, etal. Blood 2010; 116: 2543

• Waheed S, etal. Cancer 2011; 117:1001

• Use in clinical routine depends on some technical and logistical resolutions

IMWG Molecular Cytogenetic Classification(Fonseca R, etal. Leukemia 2009; 23: 2210)

• Hyperdiploid (45%)

• Non-hyperdiploid (40%)– Cyclin D translocation-18%

• t(11;14)(q13;q32)-16%

• t(6;14)(p25;q32)-2%

• t(12;14)(p13;q32)-<1%– MMSET translocation-15%

• t(4;14)(p16;q32)– MAF translocation-8%

• t(14;16)(q32;q23)-5%

• t(14;20)(q32;q11)-2%

• t(8;14)(q24;q32)-1%

• Unclassified (other) (15%)

ReferencesBergsagel PL and Kuehl WM. Oncogene2001; 20: 5611

Fonseca R, etal. Blood 2003; 101: 4569

Keats JJ, etal. Blood 2003; 101:1520

Bergsagel P, etal. Blood 2005; 106: 296

Gertz MA, etal. Blood 2005; 106:2837

Carrasco DR, etal. Cancer Cell 2006; 313

Zhan F, etal. Blood 2006; 108:2020

Stewart AK, etal Leukemia 2007; 21:529

Avet-Loiseau HA, etal. Blood 2007; 109: 3489

Shaughnessy JS, etal. Blood 2007; 109:2276

Chng WJ, etal. Leukemia; 2008; 22: 459

Decaux O, etal. J Clin Oncol 2008; 26: 4798

Avet-Loiseau H, etal. Leukemia 2013; 27: 711

Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART)

Standard Risk (60%) Intermediate Risk (20%)

t(11;14) t(4;14)

t(6;14) Del 13

Hyperdiploid Hypodiploid

All Others

(OS=8-10yrs) (OS=4-5yrs)

High Risk (20%)

Del 17p

t(14;16)

t(14;20)

GEP High Risk

(OS=3yrs)

Chesi M and Bergsagel PL. Int J Hematol 2013; 97: 313

WHO Classification of Plasma Cell Neoplasms (2008)

• Monoclonal gammopathy of undetermined significance (MGUS)

• Plasma Cell Myeloma• Asymptomatic (Smoldering)

• Non-secretory myeloma

• Plasma cell leukemia

• Plasmacytoma• Solitary plasmacytoma of bone

• Extraosseous (extramedullary) plasmacytoma

• Immunoglobulin deposition diseases• Primary amyloidosis

• Systemic Light and heavy chain deposition diseases

• POEMS syndrome (Osteosclerotic myeloma)

WHO Criteria For Symptomatic Plasma Cell Myeloma (4th Edition-2008)

• M-protein in serum or urine

• Bone marrow clonal plasma cells or plasmacytoma

• Related organ or tissue impairment

(end organ damage)

[Modified from International Myeloma Working Group. Br J Haematol2003;121749-57]

Diagnostic Criteria for Plasma Cell Myeloma (Revised 4th edition-2016)

• Clonal BM plasma cells > 10% or biopsy-proven plasmacytoma and

• End organ damage attributable to the plasma cell proliferative disorder (CRAB)

– C: high calcium levels (>11 mg/dl)

– R: renal dysfunction (Cr >2 mg/dl)

– A: anemia (Hgb< 10 g/dl)

– B: bone destruction (CT or PET-CT)

or

• One or more specific biomarkers of malignancy

Biomarkers of Malignancy in PCM

• Clonal bone marrow plasma cells > 60%

• Involved:uninvolved serum free light chain ratio >100

• >1 focal lesion on MRI studies

Diagnostic Criteria for Smoldering (Asymptomatic) Myeloma

• Both criteria must be met:

• Serum M-protein (IgG or IgA) >3.0g/dL or urinary M-protein >500mg per 24 h and/or clonal bone marrow plasma cells 10 to 60%

• Absence of myeloma defining events (CRAB) or amyloidosis

• Dispenzeri A, etal. Blood 2013;122: 4172

• 2-year time to progression rates >60%

o Extreme bone marrow plasmacytosis (>60%)

o Extremely abnormal serum free light chain ratio (>100)

o Multiple bone lesions detected only by MRI (>1 focal lesion)

• Dhodapkar MV, etal. Blood 2014; 123: 78

• 2-year time to progression rate 67%

o Elevated SFLC, M-spike, GEP70 risk score

High Risk Smoldering Myeloma

High-Risk Smoldering Myeloma

• Clinical trials have shown that asymptomatic myeloma patients with high risk features could benefit from treatment

– Delayed time to progression and improved overall survival

Monoclonal Gammopathy of Undetermined Signif. (MGUS)

• MGUS is a potentially malignant clonal plasma cell expansion (precursor lesion)

• Defined by: • M-protein in serum

< 3.0g/dl• Marrow plasma cells

< 10% and low level of infiltration in trephine biopsies

• No myeloma related end organ damage (CRAB)

Monoclonal Gammopathy of Undetermined Signif. (MGUS)

• ~3% to 4% of persons >50 years of age

• A significant minority progress to a malignant plasma cell neoplasm

• Can not be certain at diagnosis which will remain stable

Kappa

Lambda

Risk of Progression in MGUS

• Risk of progression is about 1% per year and indefinite

• Size and type of M-protein and serum free light chain ratio are most significant– M-protein of 25g/L >4 times risk of <5g/L

– IgM and IgA are at greater risk (~1.5%/yr.)• Fraction of PC with an abnormal immunophenotype

• DNA aneuploidy

• Subnormal levels of polyclonal Ig

Types of MGUS

• IgM MGUS (15%)

• Non-IgM MGUS (85%) (70%-IgG, 12%-IgA)

Differences Between IgM MGUS and Non-IgM MGUS?

• Non-IgM MGUS

– Plasma cell

– Genetics similar to myeloma

– Rate of progression is 1.0%/yr.

• IgM MGUS

– Lymphoplasmacytic

– MYD88 L265P mutation in ~50% of cases

– Rate of progression is 1.5%/yr.

Differences Between IgM MGUS and Non-IgM MGUS

• Non-IgM MGUS– Progression to plasma

cell myeloma or primary amyloidosis

• IgM MGUS– Progression to

lymphoplasmacyticlymphoma (WM) or other lymphoproliferative dis.

Premise

• IgM MGUS is a distinct biologic and clinical entity whose only relationship to IgG and IgA MGUS is the presence of secreted M-protein

Recommendation

• Segregate the two types of MGUS

– IgM or LymphoplasmacyticMGUS

– Non-IgM or Plasma Cell MGUS (includes light chain MGUS)

WHO Recommendations on Segregating IgM and Non-IgM MGUS

Definition of Light Chain MGUS

• Abnormal free light chain ratio (<0.26 or >1.65)

• Increased level of the involved free light chain

• No immunoglobulin heavy chain expression on IFE

• Urinary M-protein <500mg/24hr; Clonal plasma cells <10%

• Absence of end-organ damage (CRAB) or amyloidosis

( Up to 20% of MGUS; Rate of progression is 0.3%/year)

Plasma Cell Myeloma

> 10% plasma cells* or plasmacytoma

Smoldering Myeloma

≥3 g/dl M spike OR≥10% and <60% PCs*

MGUS

<3 g/dl M spike<10% plasma cells*

Criteria for diagnosis of PCN

NO anemia, hypercalcemia, bony lesions ,

or renal dysfunction

C: high calcium levels (>11 mg/dl)R: renal dysfunction (Cr >2 mg/dl)A: anemia (Hgb< 10 g/dl)B: bone destruction (usually lytic bone lesions) Or Biomarkers of malignancy

* in marrow

Modified from Kyle RA et al. NEJM 2002;346(8): 564-569.

Criteria for Diagnosis of Solitary Plasmacytoma

• Solitary lesion of bone or soft tissue consisting of clonal PCs

• Normal random BM biopsy without clonal PCs

• Normal skeletal survey and MRI or CT except for the solitary lesion

• Absence of end-organ damage (CRAB)

• Criteria for diagnosis of solitary plasmacytoma with minimal bone marrow involvement:

– Same as above plus clonal PCs of <10% in random BM biopsy (60% vs. 10% progression in 3yrs.)

Solitary Plasmacytoma of Bone

• 3% to 5% of PCN

• Spine is most common site (40%-50%)

• ~50% have M-protein in serum or urine

• ~ 2/3 evolve to plasma cell myeloma

• Relatively indolent

High-Risk Solitary Plasmacytoma of Bone

• Additional bone lesions identified only by MRI or PET/CT (~30% of cases)

– Significantly more likely to progress

– Considered plasma cell myeloma in new WHO

• Flow cytometry identification of occult disease

– 49% to 68% with clonal/aberrant plasma cells

– More likely to progress (70% vs 10%, med.-26 mo. vs NR)

• Presence of monoclonal urinary light chains

– More likely to progress (91% vs. 44%, med.-16 mo. vs 82 mo.)

Extraosseous Plasmacytomas

• Most Common Primary Site –

– ~ 80% in upper respiratory track (Spread to cervical nodes in~15%)

• Less Common Sites

– Lymph nodes (primary), salivary glands, thyroid, breast, GI track, CNS, etc.

• 20% have a low quantity M-protein- most IgA

• ~25% local recurrence, occasional spread to other sites

• ~15% progress to PCM

Lymph Node

Differential Diagnosis of Extraosseous Plasmacytoma

• Reactive plasma cell infiltrates

• Other lymphoid neoplasms that exhibit marked clonal plasma cell differentiation

– Marginal zone lymphoma

– Lymphoplasmacytic lymphoma

– Immunoblastic large cell lymphoma

Dual Immunostain for Kappa (brown) and Lambda (red) in Polytypic Plasma Cells

Extraosseous Plasmacytoma vs. Lymphoma with Extreme Plasma Cell Differentiation

• Presence of areas in tissue section of typical lymphoma

• IgM monoclonal protein

• Detection of clonally related lymphocytes

• PC Immunophenotype by flow cytometry

– CD19(-), CD56(+) more likely plasmacytoma

– CD19(+), CD56(-) more likely lymphoma

– CD20(+) more likely lymphoma

CD19(+) PCs:NHL--95%MM--5% Surface LC(+) PCs:

NHL—76%MM—44%

NHL with plasmacytic differentiation

Seegmiller et al, AJCP 2007;127:176-181 (Slide provided by Steve Kroft, MD)

CD45: 91% v. 41%CD56: 33% v. 71%

Abnormal B-cell population

Plasma Cell Neoplasms with Associated Paraneoplastic Syndrome

POEMS Syndrome

TEMPI Syndrome

POEMS Syndrome (Osteosclerotic Myeloma)

• Polyneuropathy

• Organomegaly

• Endocrinopathy

• M-Protein

• Skin changes

POEMS Syndrome (Osteosclerotic Myeloma)

• Paraneoplastic syndrome

• Osteosclerotic plasma cell neoplasm

• Low tumor burden with M-protein at MGUS levels

• Genetic findings similar to other plasma cell neoplasms

• Symptoms related to products produced by the clonal plasma cells directly or indirectly, eg. VEGF

• Successful treatment is directed at PCN

Lambda

Criteria for Diagnosis of POEMS Syndrome

• Mandatory

– Polyneuropathy

– Monoclonal plasma cell proliferative disorder

• Major (1 required)

– Castleman disease

– Osteosclerotic bone lesions

– VEGF elevation

• Minor (1 required)

– 6 criteria-- O, E, S,Papilledema, Thrombocytosis, Extravascular vol. overload

Reticulin

TEMPI Syndrome

• Telangiectasias

• Elevated EPO - Erythrocytosis

• Monoclonal gammopathy

• Perinephric fluid collection

• Intrapulmonary shunting

• Schroyens W, etal. Complete and partial responses of the TEMPI syndrome to bortezomib. N Engl J Med 2012; 367: 778

TEMPI Syndrome

• 10 reported cases

• Appears to be a paraneoplasticsyndrome

• Insidious onset

• M-protein at MGUS levels– Kappa light chain

• Low clonal plasma cells

• Lacking genetic studies

• Complete or partial response to bortezomib

After Bortezomib

POEMS and TEMPI in WHO-2017POEMS Syndrome

• Retain POEMS in its present status as a rare paraneoplastic syndrome associated with an osteosclerotic plasma cell neoplasm

TEMPI Syndrome

• Include TEMPI as a provisional category in the classification of plasma cell neoplasms with

a paraneoplastic syndrome

• Plasma Cell Neoplasms Associated with a ParaneoplasticSyndrome

POEMS Syndrome (Osteosclerotic Myeloma)TEMPI Syndrome (Provisional)

Revisions in the WHO Classification of Plasma Cell Neoplasms

• Monoclonal Gammopathy of Undetermined Significance– Non-IgM (Plasma cell) MGUS (Includes light chain MGUS)– IgM (Lymphoplasmacytic) MGUS

• Plasma Cell Myeloma-(New criteria)– Molecular cytogenetic categories (IMWG)– Clinical Variants

• Smoldering (asymptomatic) myeloma (High-risk symptomatic myeloma)• Non-secretory myeloma• Plasma cell leukemia

• Plasmacytoma (Changes in radiographic requirements)• Solitary plasmacytoma of bone (SPB with minimal BM involvement)• Extraosseous (extramedullary) plasmacytoma

• Immunoglobulin Deposition Diseases• Primary amyloidosis (Definition, recommendations on amyloid testing)• Systemic light and heavy chain deposition diseases

• Plasma Cell Neoplasms with Associated Paraneoplastic Syndrome– POEMS syndrome (Changes in criteria for diagnosis)– TEMPI (Provisional)

Thank you! Questions?

Immunoglobulin Deposition Diseases

• Primary amyloidosis

• Systemic light and heavy chain deposition diseases

• Characterized by visceral and soft tissue Igdeposition prior to development of a large tumor burden

• Leads to compromised organ function

Primary (Light Chain) Amyloidosis (AL)

• ~90% have M-protein, 70% lambda

72%serum

73% urine

• 7% >3 gm/dL M-protein

• Median BM plasma cells - 7%

• 20% of patients have myeloma

• t(11;14) present in > 40% of cases

Diagnostic Criteria For Amyloidosis

• Tissue biopsy showing typical morphology

• Apple green birefringence under polarized light after Congo Red stain

• Typical fibrillarultrastructure

• Bone marrow examination 56%

• Abdominal fat aspiration 80%

• Combined BM & fat aspirate 89%

(Kyle and Gentry, Sem Hematol 32:55, 1995)

Biopsy Diagnosis of Amyloidosis

Myocardial Biopsy—Light Chain Amyloidosis

Congo RedPAS

Issues in the Diagnosis of Primary Amyloidosis

• Light chain amyloidosis is associated with a clonal (neoplastic) plasma cell proliferation

• Essentially all cases of amyloidosis exhibit end organ damage

• End organ damage is caused by light chain amyloid deposition in tissues and organs

Issues in the Diagnosis of Primary Amyloidosis

• Criteria for a diagnosis of plasma cell myeloma in patients with primary amyloidosis

– 10% or more plasma cells or an

– M-protein at myeloma levels

• If plasma cell number and M-protein are not at myeloma levels a diagnosis of myeloma should not be made