Circulating Tumor and Immune Cells for Minimally Invasive Risk Stratification of Smoldering Multiple Myeloma.

PURPOSE: Early intervention in smoldering multiple myeloma (SMM) requires optimal risk stratification to avoid under- and overtreatment. We hypothesized that replacing bone marrow (BM) plasma cells (PC) for circulating tumor cells (CTC), and adding immune biomarkers in peripheral blood (PB) for the identification of patients at risk of progression due to lost immune surveillance, could improve the International Myeloma Working Group 20/2/20 model. EXPERIMENTAL DESIGN: We report the outcomes of 150 patients with SMM enrolled in the iMMunocell study, in which serial assessment of tumor and immune cells in PB was performed every 6 months for a period of 3 years since enrollment. RESULTS: Patients with >0.015% versus ≤0.015% CTCs at baseline had a median time-to-progression of 17 months versus not reached (HR, 4.9; P < 0.001). Presence of >20% BM PCs had no prognostic value in a multivariate analysis that included serum free light-chain ratio >20, >2 g/dL M-protein, and >0.015% CTCs. The 20/2/20 and 20/2/0.015 models yielded similar risk stratification (C-index of 0.76 and 0.78). The combination of the 20/2/0.015 model with an immune risk score based on the percentages of SLAN+ and SLAN- nonclassical monocytes, CD69+HLADR+ cytotoxic NK cells, and CD4+CXCR3+ stem central memory T cells, allowed patient' stratification into low, intermediate-low, intermediate-high, and high-risk disease with 0%, 20%, 39%, and 73% rates of progression at 2 years. CONCLUSIONS: This study showed that CTCs outperform BM PCs for assessing tumor burden. Additional analysis in larger series are needed to define a consensus cutoff of CTCs for minimally invasive stratification of SMM.

The role of the interdisciplinary team in subacute rehabilitation for central pontine myelinolysis.

Background: Central pontine myelinolysis is a rare condition that can result in debilitating symptoms. Recent evidence suggests a shift in hypothesized prognosis for individuals with this diagnosis and implies a valuable role for rehabilitation to address prevention of secondary complications and functional recovery. This paper describes a 30 year-old female with central pontine myelinolysis presenting with incomplete locked-in syndrome and chronicles her rehabilitative journey at a comprehensive post-acute rehabilitation center. We present discipline specific interventions and discuss the interactions of the rehabilitation team as it relates to this patient's care and progression of training.Methods: Retrospective review of medical records and face-to-face interview were use to compile data for this case report.Results: The patient demonstrated improvements in function in all areas of mobility, swallowing, communication, and self-care over the course of 6 weeks of interdisciplinary training.Conclusion: This report illustrates the critical role of a patient-centered and goal-driven interdisciplinary team approach in the rehabilitation of persons with central pontine myelinolysis.Implications for rehabilitationCentral Pontine Myelinolysis can result in profound acute disability, including incomplete locked-in syndrome.Interdisciplinary post-acute rehabilitation is beneficial in maximizing functional recovery and minimizing secondary complications for individuals with Central Pontine Myelinolysis.Ongoing clinical assessment and team collaboration contribute to progressive and comprehensive plan of care development in post-acute rehabilitation.A patient-centered and goal-driven interdisciplinary team approach facilitates improvement in outcomes across clinical domains.Recovery potential and therapeutic interventions for individuals with Central Pontine Myelinolysis need to be further explored.