Scleromyxedema

1. Scleromyxedema A 70-year-old patient presented with a one-year history of progressive tightening of the skin. Physical examination showed generalized sclerodermoid induration and discoloration of the skin, as well as decreased motility of the mouth and joints. Examination of a deep-skin biopsy specimen showed fibrosis, proliferation of fibroblasts, and interstitial deposits of mucin in the dermis.

3. Scleromyxedema Serum electrophoresis showed a monoclonal gammopathy of the IgG type, with lambda light chains. The patient died three months later owing to respiratory and cardiac failure. Scleromyxedema is a primary dermal mucinosis that is almost always associated with a monoclonal gammopathy.

4. Frequency Monoclonal Gammopathies MGUS 64% Smouldering MM 2% Multiple Myeloma 14% PCL <1% Immunocytom 6% Waldenström’s Macroglobulinemia 2% CLL 2% NHL <1% Amyloidosis Primary 8% POEMS <1% Other diseases ?

5. MONOCLONAL GAMMOPATHY Hans E Johnsen MD DMSc Professor in Medicine Department of Hematology Herlev Hospital University of Copenhagen Denmark

6. Normal B Cell differentiation Memory B Cells Plasma Cells Ig Heavy & Light chain gene rearrangement Somatic hypermutations Isotype Switch genes Hyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changesHyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changes

7. Normal B Cell differentiation Memory B Cells Plasma Cells Ig Heavy & Light chain gene rearrangement Somatic hypermutations Isotype Switch genes Hyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changesHyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changes

8. Pathogenesis Monoclonal Gammopathies Expansion of clonal B cells (=Plasma Cells): Expression of monoclonal protein: M component in plasma and/or urine. Hyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changesHyperviskositet er et kardinalsymptom v Syndroma WM Polyneuropati, organomegali, endocrinopathy and M protein+ skin changes

9. Diagnosis Monoclonal Gammopathies Serum Protein Electrophoresis Showing an M Component Migrating in the Slow Gamma Globulin Region (Left). A normal result of protein electrophoresis is also shown (right).Serum Protein Electrophoresis Showing an M Component Migrating in the Slow Gamma Globulin Region (Left). A normal result of protein electrophoresis is also shown (right).

10. Frequency Monoclonal Gammopathies MGUS 64% Smouldering MM 2% Multiple Myeloma 14% PCL <1% Immunocytom 6% Waldenström’s Macroglobulinemia 2% CLL 2% NHL <1% Amyloidosis Primary 8% POEMS <1% Other diseases ?

11. Mechanisms of Progression in Monoclonal Gammopathies.

12. Probability of Progression in Monoclonal Gammopathy of Undetermined Significance (MGUS) The top curve shows the probability of progression to a plasma-cell cancer or of an increase in the monoclonal protein concentration to more than 3 g per deciliter or the proportion of plasma cells in bone marrow to more than 10 percent. The bottom curve shows only the probability of progression of MGUS to multiple myeloma, IgM lymphoma, primary amyloidosis, macroglobulinemia, chronic lymphocytic leukemia, or plasmacytoma.

13. MULTIPLE MYELOMA Hans E Johnsen MD DMSc Professor in Medicine Department of Hematology Herlev Hospital University of Copenhagen Denmark

14. Frequency Monoclonal Gammopathies MGUS 64% Smouldering MM 2% Multiple Myeloma 14% PCL <1% Immunocytom 6% Waldenström’s Macroglobulinemia 2% CLL 2% NHL <1% Amyloidosis Primary 8% POEMS <1% Other diseases ?

16. Multiple Myeloma Heterogenous Disease Spectrum

17. Pathology Bone Marrow Disease Abnormal Plasma Cells Lytic Bone Destruction Monoclonal Immunoglobulin

22. Pathogenesis Cell Biology: Cellular hierarchy Plasma cell development Molecular Genetic: Oncogenesis IgH translocations Chromosome #14

23. Plasma Cell development

24. Pathogenesis Cell Biology: Cellular hierarchy Plasma cell development Molecular Genetic: Oncogenesis IgH translocations Chromosome #14

25. Chromosome #14 Translocations

26. Deletion of genetic material occurs when IgH switches from C? to C?, C?, or C?. Oncogenes are translocated into these switch in MM. White circles indicate a switch region of pseudo C genes. Black circles indicate a switch region of functional C genes. Boxes indicates genes. Deletion of genetic material occurs when IgH switches from C? to C?, C?, or C?. Oncogenes are translocated into these switch in MM. White circles indicate a switch region of pseudo C genes. Black circles indicate a switch region of functional C genes. Boxes indicates genes.

27. Frequency of IgH translocation Partner genes

28. Pathogenesis Cell Biology: Cellular hierarchy Plasma cell development Molecular Genetic: Oncogenesis IgH translocations Chromosome #14 Multistep proces

29. Multi-step molecular pathogenesis of multiple myeloma

30. Pathogenesis Cell Biology: Cellular hierarchy Plasma cell development Disease progression Molecular Genetic: Oncogenesis IgH translocations Chromosome #14 Multistep proces

31. Disease Progression

32. Bone Disease

38. Proposed Mechanism of Action of Drugs

40. Forrest Plot Showing the Odds Ratios and 99 Percent Confidence Intervals (CIs) for the Current Study and Two Other Published Studies Comparing Conventional Treatment with High-Dose Treatment in Patients with Myeloma.

41. WALDENSTRÖM’SMACROGLOBULINEMIA Hans E Johnsen MD DMSc Professor in Medicine Department of Hematology Herlev Hospital University of Copenhagen Denmark

42. Frequency Monoclonal Gammopathies MGUS 64% Smouldering MM 2% Multiple Myeloma 14% PCL <1% Immunocytom 6% Waldenström’s Macroglobulinemia 2% CLL 2% NHL <1% Amyloidosis Primary 8% POEMS <1% Other diseases ?

43. A 65-year-old man had an 18-month history of slowly progressive swelling and discoloration of both ears, fatigue, night sweats, weight loss, occipital headaches, and photophobia. Figure 1. A 65-year-old man had an 18-month history of slowly progressive swelling and discoloration of both ears, fatigue, night sweats, weight loss, occipital headaches, and photophobia. On examination, his ears were swollen and purplish and had several small cysts that were neither warm nor tender. The skin of his nose, cheeks, upper lip, and chin was also thickened and discolored (Panel A). He had diffuse peripheral lymphadenopathy. Funduscopy demonstrated tortuous arterioles, distended prominent veins bilaterally with diminished pulsations, and retinal hemorrhages. Serum immunoelectrophoresis revealed a monoclonal IgM spike with an IgM level of 7.7 g per liter and a relative viscosity of 18.8. The patient underwent plasmapheresis. Biopsy of the left ear revealed diffuse dermal lymphoplasmacytic infiltrates (Panel B; hematoxylin and eosin, x100), with numerous plasma cells showing intranuclear inclusions of immunoglobulin, or Dutcher bodies (arrows in Panel C; hematoxylin and eosin, x500). Examination of a bone marrow aspirate and a bone marrow–biopsy specimen showed dense infiltration with lymphoplasmacytic cells expressing monotypic IgM lambda light chains, thus confirming the diagnosis of Waldenström's macroglobulinemia. The patient's symptoms improved dramatically with plasmapheresis and the institution of chemotherapy with fludarabine, and the swelling of his ears resolved. Figure 1. A 65-year-old man had an 18-month history of slowly progressive swelling and discoloration of both ears, fatigue, night sweats, weight loss, occipital headaches, and photophobia. On examination, his ears were swollen and purplish and had several small cysts that were neither warm nor tender. The skin of his nose, cheeks, upper lip, and chin was also thickened and discolored (Panel A). He had diffuse peripheral lymphadenopathy. Funduscopy demonstrated tortuous arterioles, distended prominent veins bilaterally with diminished pulsations, and retinal hemorrhages. Serum immunoelectrophoresis revealed a monoclonal IgM spike with an IgM level of 7.7 g per liter and a relative viscosity of 18.8. The patient underwent plasmapheresis. Biopsy of the left ear revealed diffuse dermal lymphoplasmacytic infiltrates (Panel B; hematoxylin and eosin, x100), with numerous plasma cells showing intranuclear inclusions of immunoglobulin, or Dutcher bodies (arrows in Panel C; hematoxylin and eosin, x500). Examination of a bone marrow aspirate and a bone marrow–biopsy specimen showed dense infiltration with lymphoplasmacytic cells expressing monotypic IgM lambda light chains, thus confirming the diagnosis of Waldenström's macroglobulinemia. The patient's symptoms improved dramatically with plasmapheresis and the institution of chemotherapy with fludarabine, and the swelling of his ears resolved.

44. AMYLOIDOSIS Hans E Johnsen MD DMSc Professor in Medicine Department of Hematology Herlev Hospital University of Copenhagen Denmark

45. Frequency Monoclonal Gammopathies MGUS 64% Smouldering MM 2% Multiple Myeloma 14% PCL <1% Immunocytom 6% Waldenström’s Macroglobulinemia 2% CLL 2% NHL <1% Amyloidosis Primary 8% POEMS <1% Other diseases ?

46. Diagnostic Algorithm for Amyloidosis. A biopsy of tissue that shows amyloid deposits on Congo-red staining is the first step. A biopsy of tissue that shows amyloid deposits on Congo-red staining is the first step. If there is no family history of amyloidosis, the next step is to examine the patient for a plasma-cell dyscrasia by immunofixation electrophoresis of the serum and urine (Beckman Instruments, Fullerton, Calif.) and by a bone marrow biopsy with immunohistochemical staining of plasma cells for and light chains. If these are negative, the next step is to look for a mutant transthyretin (TTR) protein in serum, a mutant TTR gene in genomic DNA, or both, even if there is no family history of amyloidosis. Panel A shows an abdominal-fat aspirate stained with Congo red (amyloid deposits appear red) and viewed microscopically in normal light (x100), and Panel B shows the specimen under polarized light, demonstrating green birefringence of the amyloid deposits in the connective tissue surrounding the fat cells (x100). Immunofixation electrophoresis of serum shows a free light chain (Panel C). A bone marrow–biopsy specimen stained with antibody to light chain shows preferential staining of plasma cells as well as staining of an amyloid deposit around a blood vessel (Panel D, x400). In Panel E, isoelectric focusing of serum samples shows bands of both variant and wild-type TTR protein (arrow) from a patient with ATTR (lane 2) and a single band of wild-type TTR in normal subjects (lanes 1 and 3). Panel F shows a restriction-fragment–length polymorphism (RFLP) of DNA from amplified exon 2 of TTR after digestion with the restriction enzyme NsiI and polyacrylamide-gel electrophoresis. There are extra fragments of 4.9 and 1.5 kb in samples from patients with ATTR and the transthyretin Met 30 alleles (lanes 1 and 3) rather than the expected fragments of 6.4 and 3.2 kb (lane 2). Lane 4 shows the gel markers. A biopsy of tissue that shows amyloid deposits on Congo-red staining is the first step. If there is no family history of amyloidosis, the next step is to examine the patient for a plasma-cell dyscrasia by immunofixation electrophoresis of the serum and urine (Beckman Instruments, Fullerton, Calif.) and by a bone marrow biopsy with immunohistochemical staining of plasma cells for and light chains. If these are negative, the next step is to look for a mutant transthyretin (TTR) protein in serum, a mutant TTR gene in genomic DNA, or both, even if there is no family history of amyloidosis. Panel A shows an abdominal-fat aspirate stained with Congo red (amyloid deposits appear red) and viewed microscopically in normal light (x100), and Panel B shows the specimen under polarized light, demonstrating green birefringence of the amyloid deposits in the connective tissue surrounding the fat cells (x100). Immunofixation electrophoresis of serum shows a free light chain (Panel C). A bone marrow–biopsy specimen stained with antibody to light chain shows preferential staining of plasma cells as well as staining of an amyloid deposit around a blood vessel (Panel D, x400). In Panel E, isoelectric focusing of serum samples shows bands of both variant and wild-type TTR protein (arrow) from a patient with ATTR (lane 2) and a single band of wild-type TTR in normal subjects (lanes 1 and 3). Panel F shows a restriction-fragment–length polymorphism (RFLP) of DNA from amplified exon 2 of TTR after digestion with the restriction enzyme NsiI and polyacrylamide-gel electrophoresis. There are extra fragments of 4.9 and 1.5 kb in samples from patients with ATTR and the transthyretin Met 30 alleles (lanes 1 and 3) rather than the expected fragments of 6.4 and 3.2 kb (lane 2). Lane 4 shows the gel markers.

47. Characteristics of the Systemic Amyloidoses.

48. Clinical Features of Amyloidosis. All patients had AL amyloidosis.

49. Distribution of Organ Involvement in 445 Patients with Light-Chain Amyloidosis. The light chains are predominantly (ratio of to light chains, 4 to 1). Usually, a bone marrow plasma-cell clone, identified here by means of an immunofluorescence assay with rhodamine-labeled anti-lambda antibody (anti- ), synthesizes monoclonal light chains, which are best identified by immunofixation (IF) of serum and urine. The light chains can produce amyloid deposits in virtually every organ, with the exception of parenchymal brain tissue. Percentages indicate the frequency of dominant organ involvement. Only one quarter of the patients had involvement of a single organ at presentation; the remaining patients had involvement of two organs (36 percent) or three or more organs (39 percent). The heart mass can be markedly increased, and the interventricular septum is thickened. Involvement of the gastrointestinal tract may cause life-threatening bleeding. Shown is one example of peripheral nervous system involvement: infiltration of the carpal tunnel by amyloid, which may damage the median nerve, with consequent marked hypotrophy of the hand muscles. Soft tissues that may be infiltrated by amyloid include the tongue and the submandibular regions; bruising is typical and is caused by vascular fragility resulting from the infiltration of the vessel walls by amyloid (as indicated by the apple-green birefringence on polarized light microscopy). The light chains are predominantly (ratio of to light chains, 4 to 1). Usually, a bone marrow plasma-cell clone, identified here by means of an immunofluorescence assay with rhodamine-labeled anti-lambda antibody (anti- ), synthesizes monoclonal light chains, which are best identified by immunofixation (IF) of serum and urine. The light chains can produce amyloid deposits in virtually every organ, with the exception of parenchymal brain tissue. Percentages indicate the frequency of dominant organ involvement. Only one quarter of the patients had involvement of a single organ at presentation; the remaining patients had involvement of two organs (36 percent) or three or more organs (39 percent). The heart mass can be markedly increased, and the interventricular septum is thickened. Involvement of the gastrointestinal tract may cause life-threatening bleeding. Shown is one example of peripheral nervous system involvement: infiltration of the carpal tunnel by amyloid, which may damage the median nerve, with consequent marked hypotrophy of the hand muscles. Soft tissues that may be infiltrated by amyloid include the tongue and the submandibular regions; bruising is typical and is caused by vascular fragility resulting from the infiltration of the vessel walls by amyloid (as indicated by the apple-green birefringence on polarized light microscopy).

50. MONOCLONAL GAMMOPATHY? Hans E Johnsen MD DMSc Professor in Medicine Department of Hematology Herlev Hospital University of Copenhagen Denmark