BACKGROUND
Smoldering multiple myeloma (SMM) is a plasma cell proliferative disorder with no related organ or tissue impairment. It is associated with a risk of progression to symptomatic multiple ...myeloma (MM) of approximately 10% per year. Several prognostic factors for the progression to active disease have been identified, such as those defined by the Mayo Clinic including the proportion of bone marrow plasma cells, the serum monoclonal protein level at diagnosis and the serum immunoglobulin free light chain ratio (FLC); or those defined by the Spanish Group including the proportion of bone marrow aberrant plasma cells assessed by flow cytometry plus immunoparesis.
The presence of Bence Jones (BJ) proteinuria is a myeloma feature associated with renal function and tumor burden as well. There is lack of evidence about the role of BJ proteinuria in SMM as predictor marker of progression to symptomatic disease.
AIMS
The goal of the present study was to investigate the role of the presence of Bence Jones proteinuria at diagnosis in SMM as predictor of progression to symptomatic disease.
METHODS
We reviewed 147 medical records of SMM patients from area of Castilla y León (Spain), diagnosed between 1983 and 2013, according to the criteria of the International Myeloma Working Group. The primary endpoint was time to progression to active multiple myeloma (hypercalcemia, renal insufficiency, anemia or bone lesions).
RESULTS
147 patients with SMM were included in the analysis. The median age at diagnosis was 69 years-old (range: 34-90).The serum M-protein at diagnosis ranged from 1 to 26 g/l (median,25). 70% of SMM were Ig G subtype. The proportion of bone marrow plasma cells ranged from 1% to 55% (median, 14). In 64 % of SMM, the percentage of aberrant plasma cells assessed by flow cytometry was superior to 95% and 51% had immunoparesis. Bence Jones proteinuria was detected at diagnosis in 40 patients (27%) and the average amount of urinary monoclonal light chain was 236 mg per 24h. Of those patients, 58% had a monoclonal kappa light chain. The FLC ratio was assessed in 18 patients and it was abnormal (<0.26 or >1.65) in 83% of them. The median level of involved Immunoglobulin was 88.5 mg/l (range, 13-1200) and the median ratio of involved to uninvolved was 10.8 (range, 2.2-3360). In 4 patients, FLC ratio was greater than 100.
At a median follow-up of 54 months, progression to active disease occurred in 49%. Anemia was the most common CRAB feature at the time of progression. Median time to progression (TTP) to symptomatic disease in the whole series was 63 months. SMM with BJ proteinuria had a significantly shorter median TTP to active disease as compared with patients without BJ proteinuria (21.7 months vs 82.9 months ;HR: 2.44, IC 95%: 1.48-4.02; p<0.001). The progression risk at 2 years in the BJ group of SMM was 53%.
Multivariate analysis selected BJ proteinuria at diagnosis as an independent variable for progression to symptomatic MM (HR: 2.47, IC 95%: 1.32-4.63; P=0.005). Using this independent variable, we identified 4 risk categories according to amount of urinary monoclonal light chain: 0 mg per 24h; 1-250 mg/24h; 251-500 mg/24h ; or more than 500 mg/24h, with a median TTP of 83, 37, 16 and 7 months, respectively; p <0.001.
CONCLUSIONS
The presence of Bence Jones proteinuria at diagnosis in SMM patients is associated with significantly higher risk of progression to active MM (53% risk of progression at 2 years). Moreover, the presence of more than 500 mg of BJ proteinuria can be considered as a marker for the identification of ultra high risk SMM.
No relevant conflicts of interest to declare.
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Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare ...HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors.
Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012–June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort.
882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6% vs. 2.5%; P < 0,0001 and 9.3% vs. 2.9%; P < 0.0001) and higher postoperative complications rate (21.9% vs. 14.6 %; P = 0.02).
Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences.
HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.
La hernia incisional (HI) es una complicación frecuente. El objetivo principal de este estudio es comparar, las características, complicaciones y recurrencias de las HI producidas por la colocación de un trocar laparoscópico umbilical (M3T) con la de misma localización tras cirugía abierta (M3O); y de forma secundaria la identificación de factores de riesgo.
Estudio observacional transversal analizando al registro EVEREG durante el periodo entre Julio 2012 y Junio 2018. Las variables principales fueron recurrencias y complicaciones postoperatorias. Se compararon ambos grupos (M3T y M3O). Se realizó regresión logística múltiple para identificar los factores de riesgo de la cohorte completa.
Se incluyeron un total de 882 casos. El grupo M3O presentó un ASA superior, HI con criterios de mayor complejidad para la reparación, mayor número de recurrencias a los 12 y 24 meses (8,6%vs. 2,5%; P < 0,0001 y 9,3% vs. 2,9%; P < 0,0001 respectivamente) y complicaciones postoperatorias (21,9% vs. 14,6%; P = 0,02). Se identificaron como factores de riesgo para la aparición de complicaciones postoperatorias la reparación previa, la duración de la intervención y el requerimiento de procedimientos asociados, y para las recidivas: la ausencia de especialista de pared abdominal, la reparación previa y la aparición de complicaciones. El análisis por puntuación de propensión no detectó diferencias significativas en complicaciones y recurrencias.
Las HI M3 de trocar umbilical son menos complejas que las originadas por cirugía abierta. La complejidad no se relaciona con el origen de la hernia sino con sus características y las del paciente.
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