Asymptomatic Myeloma Research Articles

Dynamic Contrast-Enhanced Magnetic Resonance Imaging Identifies a Subgroup of Patients with Asymptomatic Monoclonal Plasma Cell Disease and Pathologic Microcirculation

The aim of our study was to investigate whether dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) allows visualization of changes in microcirculation between healthy controls on the one side and early/advanced stages of plasma cell disease on the other. We examined a group of 222 individuals consisting of 60 patients with monoclonal gammopathy of undetermined significance (MGUS), 65 patients with asymptomatic multiple myeloma (aMM), 75 patients with newly diagnosed symptomatic MM (sMM), and 22 healthy controls with DCE-MRI of the lumbar spine. A continuous increase in microcirculation parameters amplitude A and exchange rate constant kep reflecting vascular volume and permeability, respectively, was detected from normal controls over MGUS and aMM to sMM. For A and kep, significant differences were found between controls and aMM (P = 0.03 and P = 0.004, respectively) as well as controls and sMM (P = 0.001 and P < 0.001, respectively). Although diffuse microcirculation patterns were found in healthy controls as well as MGUS and MM, a pattern with focal hotspots was exclusively detected in 42.6% of sMM and in 3 MGUS and 3 aMM patients. MGUS and aMM patients with increased microcirculation patterns showed significantly higher bone marrow plasmocytosis compared with patients with a low microcirculation pattern. Our investigations substantiate the concept of an angiogenic switch from early plasma cell disorders to sMM. Pathologic DCE-MRI findings correlate with adverse prognostic factors and DCE-MRI identifies a distinct group of patients with increased microcirculation parameters in aMM and MGUS patients.

Humoral Immune Responses against the Immature Laminin Receptor Show Prognostic Significance in Patients with Multiple Myeloma.

Multiple myeloma (MM) is characterized by a highly variable clinical course. The role of an autologous tumor-specific immune control contributing to the variable length of survival in MM is poorly understood. In the current study, we investigated whether humoral immunity specific for the tumor-associated oncofetal antigen/immature laminin receptor (OFA/iLR) has a prognostic value in MM. In patients with monoclonal gammopathy of unknown significance (MGUS) we found significant levels of anti-OFA/iLR antibodies in 21 of 30 sera (70%) and in 7 of 27 (26%) patients with asymptomatic MM (AMM). In contrast, in sera from patients with progressive MM (n=67) and in normal healthy donors (HD, n=60) no humoral reactivity against OFA/iLR was present. To look on long-term persistence of humoral anti-OFA/iLR immune responses, significant and stable titers of anti-OFA/iLR-specific IgG antibodies in follow-up samples of MGUS patients were detected. IgG subclass analyses showed a predominant IgG1 and IgG3 response suggestive for a Th1-driven immune response in the vast majority of patients with MGUS and to smaller extent in patients with AMM. OFA/iLR-antibodies were capable of recognizing and selectively killing OFA/iLR-expressing myeloma cells in complement-mediated and antibody-dependent cellular cytotoxicity (ADCC) assays. To determine whether the presence of anti-OFA/iLR antibodies influenced progression-free survival (PFS), patients were analyzed according to the presence/absence of a humoral immune response against OFA/iLR protein. In a univariate analysis, the group of patients with reactive sera (n=28) showed a significantly lower probability of disease progression compared to patients with non-reactive sera (n=29). In the patient group with significant anti-OFA/iLR titers only 2 of 28 patients developed disease progression, but 18 of 29 patients with OFA/iLR non-reactive sera (p=0.001). Our data suggest that spontaneous tumor-specific humoral immune responses against OFA/iLR exist in a significant proportion of MM patients and that superior PFS in those patients could reflect autologous immune control.

Dynamic Contrast-Enhanced Magnetic Resonance Imaging Identifies a Subgroup of Patients with Asymptomatic Monoclonal Plasma Cell Disease and Pathological Microcirculation

The aim of the present study was to investigate whether dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) allows visualization of a change in microcirculation between healthy controls on the one side and early/advanced stages of plasma cell disease on the other. We examined a group of 222 individuals consisting of 60 patients with monoclonal gammopathy of undetermined significance (MGUS), 65 patients with asymptomatic multiple myeloma (aMM), 75 patients with newly diagnosed symptomatic MM (sMM) and 22 healthy controls with DCE-MRI of the lumbar spine. A continuous increase in the microcirculation parameter amplitude A reflecting vascular volume was detected from normal controls over MGUS and asymptomatic to symptomatic MM. Significant differences were found between controls and aMM (p = 0.03), controls and sMM (p = 0.001) and between asymptomatic and symptomatic MM (p = 0.02) respectively. While diffuse microcirculation patterns were found in healthy controls as well as MGUS and MM, a pattern with focal hot spots was exclusively detected in 42.6 % of sMM and in 3 patients with MGUS and 3 patients with aMM. Patients with MGUS and aMM with increased microcirculation patterns showed a significantly higher bone marrow plasmocytosis compared to patients with a low microcirculation pattern. Our investigations substantiate by means of a non invasive assessment of bone marrow microcirculation the concept of an angiogenic switch from early plasma cell disorders to symptomatic MM. Pathological DCE-MRI findings can be identified and correlate with an adverse prognostic parameter.

A multicenter, randomized clinical trial comparing zoledronic acid versus observation in patients with asymptomatic myeloma

Bisphosphonates (BPs) are effective in the prevention and treatment of skeletal-related events (SREs) in patients with symptomatic myeloma who are receiving chemotherapy. Recent data also suggest a possible antineoplastic activity of BPs. Few studies published to date have explored the role of BPs in patients with untreated, asymptomatic myeloma (AM). No data are available on the efficacy of zoledronic acid in these patients. The authors conducted a prospective, multicenter, open-label, phase 3, randomized trial comparing the administration of zoledronic acid versus simple observation in patients with AM. One-hundred sixty-three patients were enrolled and randomized (1:1) to receive zoledronic acid (n = 81 patients) or not to receive zoledronic acid (n = 82 patients) for 1 year at a dose of 4 mg monthly as a single, 15-minute, intravenous infusion. After a median follow-up of 64.7 person-months, 44.4% of patients in the zoledronic acid group and 45.1% of the control group progressed to 'symptomatic' myeloma requiring chemotherapy (P = .9307). The median time to progression was 67 months and 59 months for the treatment and control groups, respectively (P = .8312). At progression, SREs were significantly lower in the zoledronic acid-treated group (55.5%) than in the control group (78.3%; P = .041), whereas anemia, renal failure, and extramedullary disease were not statistically different. More frequent adverse events observed in the zoledronic acid-treated group were asymptomatic hypocalcemia and fever. One patient developed reversible osteonecrosis of the jaw. No renal failure caused by zoledronic acid was reported. The monthly use of zoledronic acid for 1 year in patients with AM reduced the development of SREs at progression but did not influence the natural history of the disease.

Multiple myeloma: ESMO Clinical Recommendations for diagnosis, treatment and follow-up

Detection and evaluation of the monoclonal (M) component by serum and urine protein electrophoresis (concentrate of 24-h urine); quantification of IgG, IgA and IgM immunoglobulins; characterization of the heavy and light chains by immunofixation; serum-free light-chain measurement for identifying and monitoring nonsecretory MM. Evaluation of bone marrow plasma cell infiltration. Bone marrow aspiration and biopsy are the standard option to detect quantitative and/or qualitative abnormalities of bone marrow plasma cells. Evaluation of lytic bone lesions. Full skeleton X-ray survey is recommended. Optional magnetic resonance imaging (MRI) provides greater details and is recommended if a spinal cord compression is suspected. Biological assessments to differentiate symptomatic and asymptomatic MM: hemoglobin (and full blood cell count), serum creatinine and calcium level (CRAB classification).

Final Analysis of a Multicenter, Randomised Study Comparing Zoledronate vs Observation in Patients with Asymptomatic Myeloma.

In vitro evidences suggest that bisphosponates (BP) may exert some anti-myeloma activities. Indeed, the use of BP has been associated with better survival in selected subgroups of myeloma patients. We have previously reported that pamidronate, a second generation BP, is not useful to prevent or to delay the need of chemo-radiotherapy in patients with early stage or smouldering myeloma, who do not require specific treatments at diagnosis, although such a therapy may reduce skeletal events at the time of disease progression (Musto et al, Leuk Lymphoma 2003; 44: 1545). Based on this limited evidence, the recently updated ASCO guidelines still not recommend the use of BP in this specific setting of patients (Kyle et al, J Clin Oncol 2007; 25: 2464). On June, 2001, we started a randomised clinical trial comparing zoledronate (ZOL), a third generation, more potent BP, vs simple observation in patients with monoclonal gammopathy fulfilling the diagnostic criteria of stage IA, IIA or smouldering myeloma, not requiring further treatments. These criteria substantially correspond to the current definition of “asymptomatic myeloma”, recently suggested by the International Myeloma Working Group (IMWG, Br J Haematol 2003; 121: 749). Accrual was completed on June, 2004. One-hundred-sixty patients were enrolled and randomised (1:1) to receive (n. 80) or not (n. 80) ZOL (Zometa, Novartis Pharmaceuticals. Origgio, Italy) for one year, on an out-patient basis, at the dose of 4 mg as 15′ i.v. single monthly infusion. The two groups were comparable at baseline for time from diagnosis, levels and type of M-component and percentage of bone marrow plasma cells. The most frequent adverse effects observed in ZOL-treated patients were moderate, not clinically relevant hypocalcemia (15 patients: all received oral substitutive therapy and continued the treatment) and fever (7 patients, one of whom stopped drug administration after two cycles). One patient developed reversible osteonecrosis of the jaw, none evidenced renal failure under ZOL therapy. Eight patients (two in the ZOL-treated group and six within controls) died due to unrelated reasons or were lost at follow-up after 6–26 months. No significant reduction of M-component (> 25%) was observed throughout the study in both groups. After a median follow-up of 55 months (range 36–72), there were 35 (46%) progressions to “symptomatic” myeloma in the ZOL group and 37 (50%) within the controls (p n.s.). Median time-to-progression was 42.2 and 40.7 months, respectively (p n.s.). Bone lesions and/or hypercalcemia at the time of progression were significantly lower (17/35, 48.5%) in ZOL-treated patients than in controls (30/37, 81%) (p < 0.02). These mature data suggest that the monthly use of ZOL for one year in patients with early-stage, asymptomatic myeloma is safe, reduces the development of skeletal events at progression, but does not decrease the number of evolutions and does not prolong the time to transformation into “overt” myeloma.

Technetium‐99m sestamibi scintigraphy is sensitive and specific for the staging and the follow‐up of patients with multiple myeloma: a multicentre study on 397 scans

We evaluated the additional benefit of Technetium(99)-sestamibi (99mTc-MIBI) scanning in comparison with standard X-ray techniques for multiple myeloma patients either at diagnosis or during follow-up. Between February 2001 and January 2005, 397 whole body scans were acquired. On 229 scans performed at diagnosis, 146 (64%) were positive and 81 cases have discordant X-ray results. The sensitivity of 99mTc-MIBI and X-ray were 77% and 45% respectively. As a result of 99mTc-MIBI, 40% of asymptomatic myeloma patients were up-staged. The positivity of 99mTc-MIBI correlated significantly with all of the most relevant clinical and biological parameters. Multivariate analysis selected only high reactive C protein (P = 0.0005), bone marrow infiltration (P = 0.02) and bone pain (P = 0.002) as factors affecting 99mTc-MIBI pattern. In 22 patients with solitary myeloma, 99mTc-MIBI was positive in 86% of cases and detected more disease sites than X-ray. Among 168 scans performed during follow-up, 99mTc-MIBI presented high specificity in patients showing a complete response (CR; 86%), and correlated with myeloma activity and with response to therapy. At multivariate analysis, a positive pattern correlated with bone marrow infiltration (P = 0.002) and disease status other than CR (P = 0.03). We conclude that 99mTc-MIBI scanning is an additional diagnostic tool with a high specificity for the staging and the follow-up of multiple myeloma patients.

Long-Term Results of Single-Agent Thalidomide as Initial Therapy for Asymptomatic (Smoldering or Indolent) Myeloma.

Background: Patients with early stage myeloma are typically observed without therapy until symptomatic disease occurs. We have reported early results of therapy with single-agent thalidomide as initial therapy for early stage multiple myeloma in an attempt to delay progression to symptomatic disease (Leukemia 2003; 17:775–9). We now report the long-term results of this phase II trial.Methods: Thirty-one patients with smoldering or indolent multiple myeloma were enrolled between April 1999–March 2002. All pts had bone marrow (BM) plasma cells >=10% and measurable disease defined as serum monoclonal (M) protein >=2gm/dL and/or urine M protein >=400mg/24 hours. Two patients were deemed ineligible because they were found to have received prior therapy for myeloma and were excluded from analysis. Thalidomide was initiated at a dose of 200 mg/day and increased as tolerated by 200 mg/day every 2 weeks to a maximum dose of 800 mg/day. The dose of thalidomide was decreased as needed to minimize toxicity. Treatment was continued until disease progression or serious toxicity, except for patients achieving less than a minor response (<25% paraprotein reduction) to therapy in whom therapy was stopped at one year. Response was defined as a decrease in serum and urine monoclonal (M) protein by 50% or higher. If the serum M protein was unmeasurable, a 90% or higher decrease in urine M protein was required. Responses need to be confirmed at least 4 weeks apart.Results: Ten patients (34%) had indolent myeloma, including 4 patients with lytic bone lesions, 3 patients with anemia (Hb <11gm/dL), and 3 patients with both anemia and lytic bone lesions. Median follow up of living patients is 5.6 years (range, 4.0–7.1 years). Of the twenty-nine eligible patients, ten (34%) had a partial response to therapy with at least 50% or greater reduction in serum and urine monoclonal (M) protein. Three patients are still on study and receiving therapy. The remaining have gone off-study: seven patients (27%)had progressive disease while on therapy; other reasons for ending study treatment included completed therapy per protocol (2 pts), patient refusal (2pts), toxicity (8 pts), alternate treatment (3 pts), other medical problems (1 pt), died on study (1 pt), and other (2 pts). The median time to progression (TTP) was 3.2 years (95% CI 2.1–5.6 yrs). Median progression free survival (PFS) was 3.0 yrs (95% CI 2.0–5.1 yrs). Median overall survival has not been reached; 5 year survival rate by the Kaplan Meier method is 60%. Major grade 3–4 non-hematologic adverse events at any time during therapy were noted in 34% of patients; this includes 14% with grade 4 toxicity. Grade 3–4 toxicities occurring in more than one patient include neuropathy (2 pts) and sinus bradycardia (2 pts).Conclusions: Thalidomide has activity in asymptomatic myeloma. This approach must be further tested in randomized trials to determine if the survival estimates are superior to observation. Given the activity of thalidomide, trials are also needed with lenalidomide.

Dynamic Contrast-Enhanced MRI Identifies a Distinct Group of Asymptomatic Myeloma Patients with Increased Bone Marrow Microcirculation.

Introduction: Dynamic contrast enhanced MRI (dceMRI) is an imaging technique detecting changes in local microcirculation reflecting increased angiogenesis. The dceMRI parameters Amplitude A and exchange rate constant kep have been shown to be significantly increased in patients with active multiple myeloma (MM) compared to healthy controls and to correlate with osteolytic bone involvement and prognosis. We now compared the parameters and infiltration patterns of dceMRI in patients with monoclonal gammopathy of undetermined significance (MGUS) as well as in patients with asymptomatic MM not requiring chemotherapy (NRC-group) with those in patients with symptomatic MM requiring chemotherapy according to international standards.Methods: The NRC group contained 71 patients: 29 patients with MGUS, 39 patients with MM stage I and 3 patients with MM stage IIA according to Durie and Salmon. 24 patients had a diagnosis of a MM in stage II in progression (n = 3) or stage III (n = 21). All patients underwent standardized dceMRI with high temporal resolution (T1w-turboFLASH) of the lumbar spine before start of therapy. Color coded pharmacokinetic maps of imaged area were classified according to three distinct patterns of microcirculation: “normal” (as in healthy controls), “diffuse” or “focal”. The contrast uptake was quantified using a two compartment model with the output parameters Amplitude A and distribution constant rate kep reflecting bone marrow microcirculation.Results: 63 % of patients in the NRC group were found to have changes in the microcirculation pattern with 26 patients (37%) displaying a normal, 43 (60%) a diffuse and 2 (3%) a focal pattern. Within the NRC group 11 MGUS patients (38%) were found to have a normal pattern, 17 patients (59%) had a diffuse and 1 patient (3%) presented with a focal pattern. 79 % of patients with symptomatic MM had an abnormal microcirculation pattern with 5 (21%) MM patients showing a normal, 12 (50%) a diffuse and 7 (29%) a focal pattern. Statistical comparison did not reveal a significant difference in the total incidence between NRC and symptomatic MM group.Comparison of quantitative microcirculation parameters did not show a significant difference of Amplitude A (p=0.87) and exchange rate constant kep (p=0.3) in MGUS patients compared to patients with asymptomatic MM. Comparing the NRC group with the symptomatic myeloma group revealed a significant higher Amplitude A in the symptomatic MM group (p=0.01). There was no significant difference in exchange rate constant kep.Conclusion: Our investigations revealed a group of patients with asymptomatic myeloma and MGUS that display significant increase in bone marrow microcirculation. Our findings could be the basis for stratified treatment of patients with novel therapeutics targeting the vascular system. Prognostic implications for systemic and local development of the malignant disease are topic of current investigations.

Diffuse MRI Pattern of Marrow Infiltration Correlates with Suppressed Bone Formation and Increased Incidence of Vertebral Fractures in Multiple Myeloma.

Bone lytic disease is a major feature of multiple myeloma (MM) and is characterized by an increased osteoclast activity which is accompanied by a suppressed osteoblast function. Furthermore, increased angiogenesis is implicated in the pathogenesis of both bone disease and myeloma cell growth and survival. Magnetic resonance imaging (MRI) pattern of bone marrow involvement correlate with prognosis in MM. The aim of this study was to evaluate the MRI pattern of marrow infiltration in correlation with markers of bone remodeling and angiogenesis in 44 newly diagnosed, untreated, MM patients (42 with symptomatic and 2 with asymptomatic MM). MRI of the spine was performed at the same time with measurement of a series of biochemical serum indices of bone metabolism and angiogenesis:osteoclast stimulators [soluble receptor activator of nuclear factor-κB ligand (sRANKL), osteoprotegerin (OPG), and osteopontin],bone resorption markers [C- and N-telopeptide of collagen type-I (CTX, and NTX, respectively), and tartrate-resistant acid phosphatase isoform 5b (TRACP-5b)],bone formation markers [bone alkaline phosphatase (bALP), and osteocalcin (OC)], andangiogenic cytokines [vascular endothelial growth factor (VEGF), VEGF-A, angiogenin (ANG), angiopoietin-2 (ANGP-2), and basic fibroblast growth factor (bFGF)].Myeloma patients had increased values of sRANKL (p<0.0001), OPG (p=0.01), sRANKL/OPG ratio (p<0.0001), NTX (p<0.0001), CTX (p=0.04), TRACP-5b (p<0.0001), VEGF (p=0.03), VEGF-A (p<0.0001), ANG (p<0.001), ANGP-2 (p=0.001), and bFGF (p=0.007) compared with respective values of 33, gender and age matched, controls. MRI revealed that 19 patients had focal pattern of marrow involvement, 11 diffuse, 10 normal, and 4 had a variegated pattern. Patients with diffuse MRI pattern also had reduced values of bALP (p<0.0001) compared to controls, while patients with normal pattern had reduced levels of both formation markers (OC and bALP; p=0.04 and <0.0001, respectively) and normal levels of OPG. On the contrary, patients with focal and variegated patterns had normal values of bALP and OC. Bone formation as assessed by bALP was more suppressed in patients with diffuse or normal MRI patterns compared to patients of focal or variegated patterns (mean±SD: 15.9±7.3 U/L vs. 29.3±24.5 U/L; p=0.02), while there was no difference between these groups in terms of resorption markers or osteoclast stimulators' levels. In addition, patients with diffuse and normal MRI pattern also had increased levels of VEGF-A compared to patients of focal or variegated patterns (mean±SD: 83±68.4 pg/mL vs. 38.4±55 pg/mL; p=0.04). All but two patients of diffuse pattern (81%) had at least one vertebral fracture on radiographic evaluation of the axial skeleton compared to ten patients with focal pattern (52%). These results suggest that patients with diffuse MRI pattern have suppressed bone formation, increased levels of the major angiogenic cytokine VEGF-A, and increased incidence of vertebral fractures compared to patients who showed a focal pattern of myeloma infiltration.

Angiogenesis in Multiple Myeloma (MM): Angiogenic Switch or Reflexion of Plasma Cell Number? A Gene Expression Based Survey in Primary Myeloma Cells and the Bone Marrow Microenvironment.

BACKGROUND. Angiogenesis is a hallmark of active multiple myeloma. However, two etiologic hypotheses have been proposed:an angiogenic switch (i.e. differential or de novo expression of pro/antiangiogenic genes in MM), and, alternativelyan effect of increased plasma cell number.AIM of this study was to investigate the angiogenic signature of multiple myeloma cells (MMC), normal bone marrow plasma cells (BMPC), the bone marrow microenvironment (BMME) and cellular subfractions therein.PATIENTS AND METHODS. 128 newly diagnosed MM-patients (65 training (TG) / 63 independent validation group (VG)) and 14 normal donors (ND) were included. Bone marrow aspirates were CD138-purified by activated magnetic cell sorting. Whole bone marrow (n=49) and FACSAria sorted subfractions thereof (n=5) were investigated. RNA was in-vitro transcribed and hybridised to Affymetrix HG U133 A+B GeneChip (TG) and HG U133 2.0 plus arrays (VG). Expression data were gcrma-normalised and the empirical Bayes algorithm used. p-Values were adjusted using the Benjamini-Hochberg method (Bioconductor). iFISH was performed on purified MM-cells using probesets for chromosomes 1q21, 9q34, 11q23, 11q13, 13q14, 15q22, 17p13, 19q13, 22q11 and the translocations t(4;14) and t(11;14). HGF expression was verified by real time RT-PCR and western blotting. Based on Medline review, we established a list of 89 pro- and 56 antiangiogenic genes and investigated their expression according to the stage of disease: BMPC vs. MGUS, SD stage I (asymptomatic myeloma) vs. SD stage II/III (symptomatic myeloma requiring therapy).RESULTS.BMPC express pro- (e.g. VEGFA) and antiangiogenic genes (e.g. TIMP2).Only one pro-angiogenic gene (hepatocyte growth factor, HGF) is significantly overexpressed in MMC compared to BMPC. HGF has previously been linked with myeloma progression and induction of angiogenesis.Six antiangiogenic genes (TIMP2, SERPINF1, COL18A1, PF4, THBS1, CXCL14) are downregulated in MMC compared with BMPC.Compared to healthy donors, the BMME of MM shows a significant downregulation of PLAU (urokinase, antiangiogenic) and upregulation of TNF(proangiogenic).CONCLUSION. Upregulation of HGF-expression, downregulation of TIMP2, SERPINF1, COLA18A1, PF4, THBS1 and CXCL14 expression in MMC as well as downregulation of PLAU and upregulation of TNFα in the BMME seem to indicate an “angiogenic switch”. However, given the relatively low number of differentially expressed genes (7/145) and the expression of angiogenic genes by BMPC, an effect caused by an increasing number of plasma cells might be evenly important.

Guidelines on the diagnosis and management of multiple myeloma 2005

In 2001, guidelines for the diagnosis and management of myeloma were published by the Guidelines Working Group of the UK Myeloma Forum (UKMF) on behalf of the British Committee for Standards in Haematology (BCSH) (UK Myeloma Forum; British Committee for Standards in Haematology, 2001). That same year, the second edition of guidelines prepared by the Nordic Myeloma Study Group (NMSG) in 1995 was issued (in the Scandinavian languages; http:// www.myeloma-nordic.org). As both sets of guidelines were intended to be evidence based, it was reassuring to note that the recommendations were similar. Subsequently, informal contact between members of the two groups led to the decision to prepare these common, updated guidelines. These revised and updated guidelines include new sections on imaging and the management of skeletal disease, cover new developments in disease classification and staging and the use of new therapeutic approaches, such as thalidomide, bortezomib and reduced-intensity allogeneic transplantation. The guidelines are presented in specific sections as follows:

Gene Expression Profiling of Bulk CD138+ Plasma Cells in Preneoplastic Gammopathy/Asymptomatic Myeloma Identifies Distinct Subsets of Patients.

Gene expression profiling of plasma cells (GEP-PC) has provided major insights into myeloma pathobiology. However the data about GEP-PC in preneoplastic gammopathy (MGUS) or asymptomatic myeloma (AM) are limited, and gene expression patterns that might predict outcome in these patients have not been defined. We analyzed GEP (using U133Plus Affymetrix microarrays), of plasma cells isolated by immuno-magnetic bead selection with CD138 microbeads, from the bone marrow of patients with MGUS (n=16) and asymptomatic myeloma (AM; n=18) enrolled in a prospective South West Oncology Group (SWOG) observational study. Data from normal plasma cells (PCs) and from 105 myeloma PCs were included as controls. Myeloma PCs were randomly selected to include at least 15 patients from each of the 7 subgroups previously identified based on GEP of myeloma tumor cells (Zhan and Shaughnessy, ASH 2004). After the suppression of immunoglobulin (Ig) genes, there were 1297 genes that significantly differed in expression between MGUS-PCs and MM-PCs, and 1099 genes that differed between MGUS-PCs and normal PCs with a 1% false discovery rate. Hierarchical cluster analysis of all samples was performed using 1000 plasma cell signature genes that were most differentially expressed between normal and myeloma PCs. These data demonstrated that both MGUS and AM samples were distributed between normal and MM samples. A prediction analysis of microarrays (PAM) model (PNAS 99:6567, 2002) utilizing 134 genes was then developed to determine if the signature from these genes in MGUS/AM was more similar to normal or to myeloma plasma cells. In this analysis, 11/16 (69%) of the MGUS samples were more similar to normal PC, compared to 6/18 (33%) of the AM samples (p=0.04). At present, there are no reliable phenotypic markers to distinguish between normal and malignant PCs within the bulk CD138+ population. Gene expression spikes for cyclin D1 and MAF/MAF-B were seen in both MGUS and AM cohorts, including in some patients with normal PC signature. These data provide the largest comparison to date, of GEP of PCs in preneoplastic versus malignant gammopathies and suggest that GEP may be a useful tool to prospectively identify subsets of patients within the MGUS/AM population with dominant normal PC or MM PC signatures, and potentially differing prognosis. Further analysis of differentially expressed genes between MGUS/MM PCs identified in this dataset may allow insights into the genomic changes in tumor cells underlying the malignant progression of myeloma.

Multiple myeloma and fever of unknown origin: a need for therapy

British Journal of Cancer (2005) 93, 266. doi:10.1038/sj.bjc.6602693 www.bjcancer.comPublished online 12 July 2005& 2005 Cancer Research UKSir,In their concise review on evolving treatment strategies formyeloma, Morgan and Davies (2005) stated that ‘early death was,and still is, a significant problem, and addressing the causes of thisis important including early diagnosis, the treatment of infection,hydration and the choice of the most appropriate chemotherapy’.The most common presenting symptoms of the disease are fatigue,bone pain and recurrent infections. The latest classificationsystem, recently released from The International Myeloma Work-ing Group (2003), highlighted the importance to distinguishbetween asymptomatic and overt myeloma, because only thelatter requires active treatment. According to this statement, thebiological activity of the disease, more than the tumour mass,is the foremost guide to the therapy. The related organ or tissueimpairment (ROTI) that meets the criterion for the diagnosisconsists of hypercalcemia, renal insufficiency, anaemia or bonelesions (a group of findings referred to as CRAB). However, weneed to understand that some of the clinical features of the disease,as the degree of anaemia, are not completely explained by theplasma cellular infiltrates or paraprotein secretion. Althoughuncommonly, myeloma can present as fever of unknown origin(FUO) (Mueller et al, 2002; Lambotte et al, 2003). In these cases thefever is attributable to the disease itself, and indeed no infectionsare demonstrable, even with extensive work-up. Moreover, thefever cannot be abated with antibiotics although chemotherapyworks well (Mumoli et al, 2004). It is not already known if themodulation of the interaction between the neoplastic clone andthe marrow microenvironment, as is the case during therapywith bortezomib, could reverse this kind of presentation; thiscould in turn result in delaying chemotherapy, at least in patientsnot eligible for transplantation procedures. Morgan and Daviesconclude saying that in the future it will be desirable to describemyeloma as a treatable disease with prolonged survival andgood quality of life if the correct treatment decisions are made.We agree with this and we add, moreover, if the correct diagnosishas also been made. We therefore suggest that FUO shouldbe mentioned as an indication for diagnosis and therapy inmyeloma patients.

Evaluation and prognostic value of serum osteoprotegerin in multiple myeloma

An essential cytokine system for osteoclast biology consists of the receptor activator of nuclear factor (NF)-B ligand (RANKL), its receptor RANK, and the soluble decoy receptor osteoprotegerin (OPG). Myeloma plasma cells have been shown to increase RANKL expression and to decrease OPG availability in the bone marrow microenvironment. These effects result in an increased RANKL:OPG ratio that favours the activation of osteoclasts. Conflicting reports exist regarding serum OPG levels in multiple myeloma (MM) and their correlation with lytic bone disease and survival (Seidel et al, 2001; Lipton et al, 2002; Kraj et al, 2003; Terpos et al, 2003; Corso et al, 2004; Kyrtsonis et al, 2004). We evaluated the serum levels of OPG in 140 newly diagnosed MM patients and assessed its prognostic value in the 101 symptomatic patients requiring treatment. The mean (± standard deviation) OPG levels in symptomatic MM, asymptomatic MM and controls represented by 41 healthy age- and sex-matched individuals were 3.4 ± 2.5, 2.9 ± 1.1 and 2.0 ± 0.7 ng/ml respectively. The median OPG concentration in symptomatic MM, asymptomatic MM and controls were 3.0 ng/ml (range, 0.8–24), 2.6 (1.6–7.2) and 1.6 ng/ml (1.2–3), respectively. OPG levels were higher in asymptomatic and symptomatic MM compared with controls (P < 0.001 in each case). In contrast, there was no statistically significant difference between asymptomatic and symptomatic MM patients (P = 0.28). Bone lesions were graded in three groups according to a standard radiographic evaluation: no osteolytic lesions, 1–6 lesions, >6 lesions. We found no significant differences of OPG values between the three groups. Significant correlations were found with β2-microglobulin (r = 0.23; P = 0.02) and creatinine (r = 0.22; P = 0.03) but not with haemoglobin, bone marrow plasmacytosis, M-component, albumin, lactate dehydrogenase (LDH) or C-reactive protein (CRP) levels. We assessed the prognostic value of OPG on overall survival (OS) and progression-free survival (PFS) in symptomatic patients. Median follow-up of the 101 patients was 68.4 months [95% confidence interval (CI): 60.2–76.6]. The median PFS and OS were 18.8 months (95% CI: 14.5–23.1) and 39.8 months (95% CI: 29.6–50.0) respectively. High serum levels of OPG were associated with a poorer OS and PFS in univariate analysis (P = 0.025 and P = 0.029 respectively) (Fig 1A,B). The other adverse prognostic factors were age >60 years (P = 0.019), albumin <35 g/l (P = 0.015), β2-microglobulin >2.5 mg/l (P = 0.025), bone marrow plasmacytosis >15% (P = 0.048), chromosome 13 deletion (P = 0.002), CRP > 16 mg/l (P = 0.037), IgA isotype (P = 0.012), LDH > 350 IU/l (P = 0.016), λ light chain (P = 0.021) for OS and β2-microglobulin >2.5 mg/l (P = 0.01), chromosome 13 deletion (P = 0.002), and IgA isotype (P = 0.012) for PFS. Interestingly, multivariate analysis showed that OPG ≥2.4 ng/ml remained an adverse independent prognostic factor for OS [relative risk (RR) 2.3, 95% CI: 1.2–4.5, P = 0.018] together with albumin <35 g/l (RR 2.4, 95% CI: 1.3–4.5, P = 0.005) and CRP >16 mg/l (RR 2.3, 95% CI 1.2–4.2, P = 0.008). Overall survival (A) and progression-free survival (PFS) (B) of the 101 symptomatic MM patients according to serum OPG level at diagnosis. The biological role of OPG in MM is possibly more complex than expected. There is no clear evidence that serum OPG reflects the availability of OPG in the bone marrow environment and we cannot exclude that OPG may have different functions on bone biology and tumor progression. OPG is a decoy receptor for tumour necrosis factor-related apoptosis-inducing ligand (TRAIL), which inhibits TRAIL-induced apoptosis. In relation to this activity, it has been recently suggested that OPG may be a survival factor for human prostate cancer cells (Holen et al, 2002) and also function as a paracrine survival factor for human myeloma cells (Shipman & Croucher, 2003). These results, if they translate in vivo, raise the possibility that OPG might have the capacity to function as a deleterious factor on MM progression in some patients.

Abnormal Cytogenetics and Significant Bone Marrow Plasmacytosis are Predictive of Early Progression and Short Survival in Patients with Low Tumor Mass Asymptomatic Multiple Myeloma

In order to evaluate the prognostic factors for progression and survival in patients with a low tumor mass asymptomatic multiple myeloma (MM), we studied 59 patients who had a long term follow-up. Cytogenetic abnormalities (using conventional cytogenetics) were observed in 14 out of 45 analyzable patients (31%). An abnormal karyotype and a bone marrow (BM) plasmacytosis > 15% were found to be adverse prognostic factors for progression in univariate and multivariate analysis.

Serum Free Light Chain Levels in Asymptomatic Myeloma.

Introduction: Patients with asymptomatic myeloma fulfil two of the diagnostic criteria for myeloma having more than 10% bone marrow plasma cells and an M protein of greater than 30g/l, but they are asymptomatic with no evidence of end organ or tissue damage. The median time to disease progression is 12–32 months. These patients do not require treatment but do require monitoring for progression to symptomatic myeloma. Predicting progression of asymptomatic myeloma would be of clinical benefit to optimise monitoring and initiate treatment prior to substantial end organ damage. However monoclonal spike, plasma cell labelling index, bone marrow plasmacytosis, immunoparesis and the presence of Bence Jones protein have limited value in predicting progression. Abnormal levels of serum free light chains are present in 95% of all multiple myeloma patients and have clinical benefit in diagnosis and monitoring of disease. In monoclonal gammopathy of undetermined significance (MGUS) 60% of patients have abnormal serum free light chain ratios and are an independent risk factor for progression to myeloma. The aim of this study was to examine the serum of asymptomatic patients for serum free light chains at diagnosis and to determine if they are predictive of disease progression.Methods: Archived presentation sera were studied from forty three asymptomatic myeloma patients who had been registered into United Kingdom Medical Research Council trials (1980 – 2002). Archived presentation sera were assayed for serum free light chains using the serum free light chain assay on an Olympus AU400 analyzer. Times to progression for those with abnormal versus normal serum free light chain ratios were compared. Times to progression were examined by Kaplan-Meier survival curves and log-rank sum statistical analysis.Results: Abnormal serum free light ratios were present in 36/43 (84%) of asymptomatic myeloma patients at the time of diagnosis and the remaining 7 patients had normal ratios. The median follow-up time for all 43 patients was 2807 days. Six patients with a normal kappa/lambda ratio had a median time to progression of 1323 days. In contrast, 26 patients with abnormal serum free kappa/lambda ratios had a median time to progression of 713 days. Ten patients who had an abnormal kappa/lambda ratio had not progressed at the time of follow-up. Although the median time to progression of patients with normal serum free light chain ratios was greater than those with abnormal ratios, this did not reach statistical significance (p<0.13).Conclusions: In summary, 84% of asymptomatic myeloma patients have an abnormal kappa/lambda ratio at diagnosis, in comparison with 95% of multiple myeloma and 60 % of (MGUS) patients. Furthermore, our data suggest that those with normal serum free light chain ratio may progress more slowly than those with abnormal ratios. Due to the small number of patients in this study, this did not reach statistical significance. In the spectrum of malignancy from MGUS to asymptomatic and symptomatic myeloma serum free light chain levels have an increasing frequency of abnormality and are associated with increased risk of progression to symptomatic myeloma.

Prognostic Factors and Outcome of Older Patients with Symptomatic Multiple Myeloma: A Study of the Greek Myeloma Study Group (GMSG).

Introduction: Prospective randomized trials have shown that high dose therapy with autologous stem cell transplantation may improve the survival of patients with multiple myeloma (MM). This procedure is usually applied to patients ≤70 years of age. Nevertheless, many patients with MM are diagnosed at an older age and are usually treated with conventional chemotherapy. We performed a retrospective analysis in order to compare the prognostic factors and outcome of younger patients with myeloma (≤ 70 years) with those of older patients (>70 years). We also applied the recently proposed International Staging System (ISS) for multiple myeloma in the two groups of patients.Patients and Methods: Since 1987, 1162 patients with symptomatic myeloma requiring treatment have been included in the data base of GMSG. Patients with asymptomatic myeloma were not included. 357 patients (31%) were > 70 years at the time of initial treatment. Multiple clinical and laboratory variables were evaluated in patients >70 years of age and in younger patients. Furthermore, the same variables were assessed for possible correlation with prognosis in patients >70 years of age.Results: The only variable that was different between the two groups of patients was the ISS with older patients presenting more often with advanced ISS (p=0.02). Older patients received more often primary treatment with standard alkylating agents - corticosteroid combinations whereas younger patients received more often primary treatment based on high dose pulse dexamethasone (VAD etc) (p=0.001). Response to treatment was similar but patients ≤ 70 years had a median survival of 40 months versus 29 months for older patients (p<0.001). Variables associated with shorter survival for the group of older patients were: anemia, thrombocytopenia, hypercalcemia, renal impairment, more extensive bone marrow plasmacytosis, elevated serum LDH and advanced ISS (2+3). A Cox regression analysis showed, that adjusting for the effects of other factors, elevated LDH, bone marrow plasmacytosis and advanced ISS retained prognostic significance in this group of older patients (median survival of 12 months, 22 months and 21 months respectively). However patients >70 years of age with ISS 1 had a relatively long median survival of 55 months.Conclusions: The clinical and laboratory characteristics of older patients with MM are similar to those of younger patients but older patients tend to present with more advanced ISS. The survival of older patients is shorter than that of younger patients. Elevated serum LDH, advanced ISS, and increased bone marrow plasmacytosis may identify older patients with particularly bad prognosis. Older patients with poor prognosis should be entered into clinical trials in order to see if treatment with new agents or combinations would prolong their survival. The application of ISS in patients >70 years of age permitted the identification at diagnosis of a subgroup of patients with ISS 1 who had a relatively good prognosis.

Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group

The monoclonal gammopathies are a group of disorders associated with monoclonal proliferation of plasma cells. The characterization of specific entities is an area of difficulty in clinical practice. The International Myeloma Working Group has reviewed the criteria for diagnosis and classification with the aim of producing simple, easily used definitions based on routinely available investigations. In monoclonal gammopathy of undetermined significance (MGUS) or monoclonal gammopathy, unattributed/unassociated (MG[u]), the monoclonal protein is < 30 g/l and the bone marrow clonal cells < 10% with no evidence of multiple myeloma, other B-cell proliferative disorders or amyloidosis. In asymptomatic (smouldering) myeloma the M-protein is >/= 30 g/l and/or bone marrow clonal cells >/= 10% but no related organ or tissue impairment (ROTI)(end-organ damage), which is typically manifested by increased calcium, renal insufficiency, anaemia, or bone lesions (CRAB) attributed to the plasma cell proliferative process. Symptomatic myeloma requires evidence of ROTI. Non-secretory myeloma is characterized by the absence of an M-protein in the serum and urine, bone marrow plasmacytosis and ROTI. Solitary plasmacytoma of bone, extramedullary plasmacytoma and multiple solitary plasmacytomas (+/- recurrent) are also defined as distinct entities. The use of these criteria will facilitate comparison of therapeutic trial data. Evaluation of currently available prognostic factors may allow better definition of prognosis in multiple myeloma.

Solitary plasmacytoma of bone and asymptomatic multiple myeloma

Most patients with multiple myeloma (MM) present with symptoms, have evidence of generalized disease, and require chemotherapy promptly to reduce the malignant clone. Some patients present with a local symptom from a single plasmacytoma but no myeloma elsewhere. Such patients usually become free of symptoms after local radiotherapy. In patients with MM without symptoms, the diagnosis is made on the basis of screening laboratory tests. In patients with either solitary plasmacytoma of bone or asymptomatic MM, systemic treatment should be deferred until there is evidence of disease progression.