Volume 206, Issue 3 pp. 817-831
REVIEW

Update on B-cell maturation antigen-directed therapies in AL amyloidosis

Krzysztof Jamroziak

Corresponding Author

Krzysztof Jamroziak

Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland

Correspondence

Krzysztof Jamroziak, Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland.

Email: [email protected]

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Klaudia Zielonka

Klaudia Zielonka

Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland

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Jahanzaib Khwaja

Jahanzaib Khwaja

Department of Haematology, University College London Hospital, London, UK

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Ashutosh D. Wechalekar

Ashutosh D. Wechalekar

Department of Haematology, University College London Hospital, London, UK

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First published: 02 January 2025
Citations: 2

Krzysztof Jamroziak and Klaudia Zielonka contributed equally to this work.

Summary

Systemic light chain (AL) amyloidosis is a rare clonal plasma cell disorder characterized by the production of amyloidogenic immunoglobulin light chains, which causes the formation and deposition of amyloid fibrils, leading to multi-organ dysfunction. Current treatment is directed at the underlying plasma cell clone to achieve a profound reduction in the monoclonal free light chain production. The standard-of-care first-line therapy is a combination of daratumumab, cyclophosphamide, bortezomib and dexamethasone (D-VCd regimen), resulting in high rates of haematological and organ responses. However, AL amyloidosis remains incurable, and all patients inevitably relapse. Hence, novel treatment options are needed for patients with an inadequate response or relapsed/refractory disease. B-cell maturation antigen (BCMA) is a tumour necrosis factor (TNF receptor superfamily receptor overexpressed on plasma cells in multiple myeloma (MM) and AL amyloidosis. Recently, several novel anti-BCMA immunotherapies have been approved for the treatment of relapsed/refractory MM, including antibody–drug conjugate belantamab mafodotin, bispecific antibodies teclistamab and elranatamab and chimeric antigen receptor T-cell therapies idecabtagene vicleucel and ciltacabtagene autoleucel. Despite lower expression than in MM, BCMA is also a promising target in AL amyloidosis. This review aims to provide up-to-date information on the efficacy and toxicity of anti-BCMA therapy in AL amyloidosis.

Graphical Abstract

Despite the significant progress in the treatment of systemic light chain (AL) amyloidosis with the introduction of the anti-CD38 monoclonal antibody daratumumab to the first-line therapy, relapsed or refractory disease remains an unmet medical need. B-cell maturation antigen (BCMA) is overexpressed on the surface of clonal plasma cells in AL amyloidosis and, therefore, represents a potential target for immunotherapy. Recent results from small clinical trials and retrospective studies suggest high efficacy of anti-BCMA strategies in relapsed refractory AL amyloidosis, including therapies already approved for multiple myeloma (antibody–drug conjugates belantamab mafodotin, bispecific T-cell redirecting antibodies teclistamab and elranatamab and chimeric T-cell antigen receptor therapies idecabtagene vicleucel and ciltacabtagene autoleucel) as well as novel immunotherapies in early clinical development.

CONFLICT OF INTEREST STATEMENT

The authors have nothing to disclose.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.

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