In high doses with stem-cell transplantation, melphalan is an effective but toxic therapy for patients with systemic lightchain (AL-) amyloidosis, a protein deposition and monoclonal plasma cell disease. Melphalan can eliminate the indolent clonal plasma cells that cause the disease, an achievement called a complete response. Such a response is usually associated with extended survival, while no response (a less than 50% reduction) is not. Gene-expression studies and a stringently supervised analysis identified calreticulin as having significantly higher expression in the pretreatment plasma cells of patients with systemic ALamyloidosis who then had a complete response to high-dose melphalan. Calreticulin is a pleiotropic calcium-binding protein found in the endoplasmic reticulum and the nucleus whose overexpression is associated with increased sensitivity to apoptotic stimuli. Real-time PCR and immunohistochemical staining also showed that expression of calreticulin was higher in the plasma cells of those with a complete response. Furthermore, wild-type murine embryonic fibroblasts were significantly more sensitive to melphalan than calreticulin knock-out murine embryonic fibroblasts. These data have important implications for understanding the activity of melphalan in plasma-cell diseases and support further investigation of calreticulin and its modulation in patients with systemic AL-amyloidosis receiving highdose melphalan.
IntroductionSystemic light-chain (AL-) amyloidosis is a rare protein conformation and clonal plasma cell disorder associated with multiorgan failure and early death due to fibrillar tissue-deposits formed by aberrant monoclonal immunoglobulin free light chains (FLC). 1 Approximately 3000 new cases are diagnosed annually in the United States. Small numbers of clonal plasma cells in the bone marrow are usually the source of the FLC, and disease is less common than , with a case ratio of 1:4, unlike multiple myeloma in which the ratio is 3:2. 2-4 A paradox of systemic AL-amyloidosis is how apparently indolent clonal plasma cells tolerate making and secreting FLC toxic to normal tissues. High-dose melphalan with autologous stem-cell transplantation (SCT) is an effective therapy in selected patients but a treatment-related mortality of up to 15% is seen even in centers with SCT experience, and only one-third of patients at diagnosis are eligible for SCT. 4 After SCT, about one-third of patients achieve a durable complete or near complete response of the clonal plasma cell disease, while one-third achieve a partial response (ÏŸ 50% reduction), and one-third have minimal to no response. The achievement of a complete response is associated with subsequent improvement of the amyloid organ disease and extended survival, while no response is associated with progression of organ disease and shortened survival. [4][5][6] The availability of the serum free light chain assay, a measure of the toxic FLC in almost all cases, has improved management during treatment. 7 Reduction in the level of pathologic ...