Dispenzieri, Angela

7518 Background: Monoclonal gammopathy of undetermined significance (MGUS) is common, yet only a minority progress to malignant plasma-cell disorders. Mayo risk stratification uses baseline factors and is commonly implemented/validated in a Cox proportional hazards (CoxPH) framework, which may miss prognostic longitudinal patterns. Methods: We assembled 15,158 MGUS patients with longitudinal laboratory data and progression outcomes (smoldering multiple myeloma, multiple myeloma, AL amyloidosis, or Waldenström macroglobulinemia). We compared a Mayo-factor Cox proportional hazards (CoxPH) baseline versus STRaTS, a transformer-based survival model, to predict progression risk at 3-, 5-, and 10-year horizons. STRaTS leveraged longitudinal trajectories of routine labs including hemoglobin, platelets, differential counts (neutrophils/lymphocytes/monocytes), immunoglobulins (IgG/IgA/IgM), free light chains (kappa/lambda), M-spike, and creatinine. To minimize bias, we used laboratory results collected from 1–3 years after diagnosis and started follow-up at year 3; patients progressing before year 3 or lacking follow-up beyond year 3 were excluded. A total of 7,305 patients met eligibility and were split into train/validation/test cohorts of 4,383/1,461/1,461. Discrimination was assessed by concordance index (C-index). Clinical operating performance was evaluated on a held-out test cohort by comparing sensitivity and specificity at the same proportion of patients selected for intensified surveillance (same workload). Results: Among MGUS patients with complete baseline Mayo factors(N=3,388), Kaplan–Meier–estimated 3-/5-/10-year cumulative progression risk was 0.1/0.4/3.4% (Low), 3.0/4.3/7.9% (Low-Intermediate), 4.4/6.4/14.1% (High-Intermediate), and 8.9/12.5/16.9% (High). On a held-out test cohort, STRaTS demonstrated superior discrimination versus the Mayo-factor CoxPH (C-index 0.75 vs 0.538; p<0.0001). Both models were trained and evaluated on identical train/test splits. At the same surveillance workload, STRaTS achieved higher sensitivity with comparable specificity; when 40.3% of patients were selected for closer surveillance, 3-year sensitivity was 81.0% for STRaTS versus 47.6% for CoxPH (Table). Conclusions: Among MGUS patients who remain progression-free at 3 years, transformer-based survival modeling of longitudinal laboratory trajectories provides more accurate individualized conditional progression risk estimates and improved workload-matched identification of progressors compared with the conventional Mayo/Cox approach. Sensitivity/specificity (%). Operating Point Flagged % STRaTS Sens / Spec (%) CoxPH Sens / Spec (%) Int+High, 3y 40.3 81.0 / 58.5 47.6 / 58.9 Int+High, 5y 40.3 81.2 / 60.4 46.9 / 58.8 Int+High, 10y 40.3 25.0 / 56.3 23.8 / 58.7 Two-Group High (≥2 factors), 5y 5.6 37.4 / 93.4 35.4 / 93.1

Summary Renal response (RenR) in light‐chain (AL) amyloidosis is associated with a lower risk of end‐stage kidney disease and improved survival. However, substantial variation exists in the time to and depth of RenR. We investigated variables associated with RenR in a retrospective study of newly diagnosed AL amyloidosis patients ( n = 350) assessable for RenR between 2010 and 2022. RenRs were recorded at 6, 12 and 24 months and best response. Deep RenR was defined as a ≥renal very good partial response (RenVGPR, >60% reduction in 24‐h proteinuria or ≤200 mg). Logistic regression and competing risk methods were used to examine variables associated with RenR. The median age was 64 years, and median follow‐up was 5.5 years. On multivariable logistic regression, obtaining ≥HemVGPR within 6 months, kappa isotype, high baseline difference between involved and uninvolved free light chains (dFLC ≥40 mg/dL), renal stage and autologous haematopoietic stem cell transplant (AHSCT) were significantly associated with deep RenR. Cumulative incidence rates for deep RenR, treating death or renal progression as a competing event, demonstrated that early HemR, first‐line AHSCT, lower renal stage and dFLC ≥40 mg/dL significantly increased the likelihood of deep RenR. Specific clonal plasma cell features, namely light‐chain isotype and baseline dFLC levels, independently influence the timing and depth of RenRs in AL amyloidosis following treatment, in addition to renal stage and HemR.

Abstract Solitary bone plasmacytoma (SBP) and SBP with minimal marrow involvement (SBPmm) are treated similarly with definitive radiation therapy (RT) followed by observation. However, differences in the natural disease course after RT between the two, are not well described. We performed a multicenter study assessing outcomes after RT in 141 patients with SBP and 102 with SBPmm diagnosed between January 2010 and December 2024. About 92% of patients with SBPmm progressed to multiple myeloma (MM) vs 76% of those with SBP (P = .01). Among patients with SBP, 21% progressed with a second solitary bone lesion vs 4% with SBPmm (P&lt; .01). Patients with longer time to progression (TTP) after initial RT could achieve durable responses with RT to a second solitary plasmacytoma in the absence of other myeloma-defining events (MDE). Multifocal lytic bone lesions were the most common MDE, occurring in 89% and 81% of patients with SBPmm and SBP, respectively. Patients with SBPmm had a median TTP of 15 months (95% confidence interval [CI], 14-21) compared to 43 months (95% CI, 34-55) for those with SBP (P&lt; .0001); 67% with SBPmm progressed within 2 years of diagnosis. Del(17p) and 1q+ (gain or amplification) were associated with shorter TTP to MM in SBPmm, with 2-year progression rates of 100% and 82%, respectively. We report significant differences in risk and modes of progression between SBP and SBPmm. Patients with SBPmm are at particularly high risk for early progression to MM, with most developing bone disease as the MDE. These findings support prospective studies incorporating frontline systemic therapy for SBPmm.

Abstract In this systematic review, we aimed to assess the sensitivity of serum immunofixation (SIFE), urine immunofixation (UIFE), and serum free light chain (sFLC) in detecting plasma cell dyscrasia associated with light chain (AL) amyloidosis. We searched the literature using PubMed, Embase, and CENTRAL databases since inception through March 2024. We included studies reporting the diagnostic accuracy of immunofixation and/or sFLC in patients with AL amyloidosis. We used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach to assess the certainty of the evidence and QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies-2) to assess the risk of bias. After deduplication, 29 237 records were screened, and 44 studies (n = 18 071) were included. For the meta-analysis, 28 studies reported sensitivity for SIFE (n = 3390), 24 studies for UIFE (n = 2830), 19 studies for SIFE and UIFE (n = 2819), 21 studies for sFLC ratio (n = 3678), 6 studies for SIFE and sFLC ratio (n = 372), 3 studies for UIFE and sFLC ratio (n = 242), and 10 studies for all 3 tests (n = 1430). Pooled sensitivities were as follows: SIFE, 0.68 (95% confidence interval [CI], 0.62-0.73); UIFE, 0.77 (95% CI, 0.72-0.81); SIFE and UIFE, 0.89 (95% CI, 0.84-0.93); and sFLC ratio, 0.82 (95% CI, 0.78-0.86). When SIFE, UIFE, and sFLC ratio were combined, the sensitivity reached 0.99 (95% CI, 0.96-1.00). The high sensitivity of combining SIFE, UIFE, and sFLC ratio supports their use as a reliable initial testing strategy to raise suspicion for AL amyloidosis and guide decisions regarding future diagnostic modalities.

Abstract Gastrointestinal (GI) involvement is a clinically relevant but undercharacterized manifestation of systemic light chain amyloidosis (AL). We aimed to define the clinical spectrum, histologic patterns, and outcomes of symptomatic GI involvement in AL. We retrospectively analyzed 4396 patients with AL from 2010 to 2024, of whom 521 (11.9%) had provider-attributed symptomatic GI involvement; 66% had biopsy-proven GI AL. Symptoms most commonly included early satiety (61%), bowel irregularities (58%), nausea (35%), abdominal pain (28%), and dysphagia (23%). Autonomic neuropathy was frequent (43% clinician attributed; 23% via autonomic reflex testing) and contributed to dysmotility-related symptoms, often without GI biopsy positivity. Among 747 GI biopsies, mucosal infiltration predominated (71%) and was associated with bleeding (22% vs 9%), cachexia, and inferior survival, whereas vascular involvement was associated with lower bleeding risk. Combined involvement of mucosa, submucosa, and vessels conferred the worst prognosis (median overall survival [mOS], 2.4 vs 5.1 vs 7.8 years for 3 vs 2 vs 1 layer); mOS was 6.8 years and was primarily driven by cardiac stage and hematologic response (very good partial response [VGPR] or better: hazard ratio, 0.20; 95% CI 0.13-0.32), with more favorable outcomes in patients with isolated GI involvement. Cachexia and persistent diarrhea were the main drivers of morbidity, need for nutritional support, and GI-related mortality (odds ratio, 2.7 for the combined end point). GI bleeding rarely recurred after achieving VGPR or better. Overall, mucosal involvement, cachexia, and dysmotility define clinically meaningful GI AL and support systematic assessment of autonomic dysfunction as well as evaluation of the need for nutritional support as a GI-specific end point for AL trials.

Abstract Systemic light chain amyloidosis (AL) arises from monoclonal immunoglobulin light chains, but determinants of progression from precursor states remain poorly defined. In a cross-sectional cohort comprising 1950 systemic AL patients diagnosed 2010-2024, 258 (13.2%) patients with a previously diagnosed plasma cell disorder (PCD) were compared to patients with no prior PCD diagnosis. Patients with monoclonal gammopathy of undetermined signficance (MGUS) and smoldering multiple myeloma (SMM) in the former group had lower difference between involved and uninvolved FLCs (dFLC), higher M-protein, and lower rates of t(11;14) at AL diagnosis. Patients developing AL from SMM had a shorter time to AL (median 34.2 versus 61.3 months) and higher dFLC (median 28.9 versus 11.0 mg/dl) compared to those from MGUS. Patients developing AL after known multiple myeloma (MM) or lymphoplasmacytic lymphoma (LPL) commonly lacked deep hematologic response before AL (≤ very good partial response in 78% of MM, 100% of LPL patients). We additionally studied longitudinally followed cohorts of 3,966 MGUS and 426 (SMM) patients with longitudinal FLC measurements and matched follow-up, in which 1.8% of MGUS and 7.2% of SMM patients developed AL. Those patients who developed AL showed markedly higher dFLC at MGUS/SMM diagnosis and more frequent λ restriction and rates of t(11;14). Higher dFLC was associated with progressively earlier AL development; a 10% cumulative risk occurred at 20 months for patients with a dFLC >80 mg/dL but was not reached if dFLC <10 mg/dL at an estimated median follow-up of 86 months. In multivariable analysis, dFLC >6.4 mg/dL (HR 11.3) and λ isotype (HR 3.6) independently predicted AL, whereas heavy chain secretion was associated with lower risk (HR 0.2 for IgG). These findings indicate that AL risk is primarily driven by cumulative light chain exposure, refining our knowledge of AL pathophysiology and providing guidance for follow-up of patients with elevated dFLC.

ABSTRACT Oligo‐secretory and non‐secretory MM present a clinical challenge due to the difficulties in initial diagnosis, response to treatment assessment, and relapse detection. They are excluded from most clinical trials, which typically require measurable disease. We describe the characteristics and outcomes of 86 patients with secretory myeloma at diagnosis who developed an OSR, matched 1:1 to a cohort with secretory relapse (SR). With a median follow‐up of 9.3 years, 16.6% (48/289) of evaluable patients developed an OSR. Lower levels of light chains at presentation, and younger age are predictive of an OSR. The median OS since relapse of the OSR group was 4.01 (95% CI 1.625–6.395) versus 3.25 (95% CI 2.255–4.245) years in the SR control group ( p = 0.4). A third of our OSR cohort had a subsequent SR. We did not find any predictive factor for SR after OSR. The median OS of the subgroup of patients who developed a SR after OSR was 3.35 years (95% CI 1.541–5.159), versus 5.8 years (95% CI 2.072–9.528) in the group that remained oligo‐secretory ( p = 0.336). The median TTNT of the SR after OSR group was 1.68 years (95% CI 0.341–0.919) versus 4.58 (95% CI not reached‐not reached) in the group that remained oligo‐secretory ( p < 0.001).