Clinical Outcome In Multiple Myeloma Research Articles

MDR1 diplotypes as prognostic markers in multiple myeloma

The aim of this study was to evaluate the effect of diplotypes of MDR1 polymorphisms at positions 2677 and 3435 on the clinical outcome of multiple myeloma, in terms of response to the therapy and overall survival (OS). G2677T/A SNP was analysed by RFLP-PCR assay on 110 patients, treated with dexamethasone, doxorubicin (adryamicin) and vincristine regimen, followed by autologous stem cell transplantation. Treatment efficacy was not related to G2677T/A SNP, whereas the OS of G/G carriers was significantly shorter than that of T/T or G/T patients. Similar results were previously reported for MDR1 C3435T polymorphism. Given that these two single nucleotide polymorphisms are in strong linkage disequilibrium, we analyzed the effects of the most frequent haplo/diplotypes and the survival probability was lower for GC/GC patients (55%) than for GC/TT and TT/TT carriers (>80%; log-rank test, P=0.03). Interestingly, the effect of MDR1 diplotype on the OS seems to be confined to autologous stem cell transplantation nonresponders. These results support the hypothesis that genetic variability of MDR1 should be considered as an important factor that influences the clinical outcome of multiple myeloma.

IL-10-592 Polymorphism Predicts the Clinical Outcome of Japanese Patients with Multiple Myeloma and MGUS.

Introduction: Interleukin 10 (IL-10) has been reported as an anti-inflammatory cytokine and B-cell proliferation factor, and has been implicated in autoimmunity, tunorigenesis and stem cell transplantation tolerance. IL-10 is also reported to be involved in multiple myeloma (MM) cell proliferation and survival. The polymorphism of position-592, -819, and -1082 in the promoter of IL-10 gene is a strong determinant of IL-10 expression. However, it is unclear whether IL-10 polymorphisms alter the incidence and clinical outcome of MM. We examined the single nucleotide polymorphism (SNPs) located within the promoter region of IL-10 genes in patients with MM, monoclonal gammopathy of undetermined significance (MGUS) and healthy controls in Japan.Methods: Seventy nine patients with MM [age range, 40–83 years; stage I (n=9), stage II (n=20), stage III (n=50); IgG(n=47), IgA(n=12), IgD(n=1), non-secretory (n=3), Bence Jones(n=16)], 46 patients with MGUS (age range, 44–86 years), and 200 healthy controls were included. Fifteen patients with transformation of MGUS to MM were included in MM group. Genotyping in IL-10 -1082G/A, -819C/T, -592A/C was determined by the polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) technique. Genotype and allele frequencies were compared between the study groups using χ2-test. The characteristics and laboratory features of MM patients with each IL-10 promoter polymorphism were compared using χ2-tests and student t-tests. Probability values <0.05 were considered statistically significant. The Kaplan-Meier method was used in the calculation of overall survival. Overall survival curves were compared with the log-rank test.Results: IL-10-592 A/A, A/C and C/C genotype frequencies were not significantly different between MM patients (51%, 34%, and 15%) and controls (42%, 43%, and 15%). Higher frequency of −592A/A genotype was seen in our Asian control compared with Caucasian. The frequency of IL-10 -1082 and -819 were also not significantly different between MM patients and healthy controls. The IL-10-592A/C genotype was detected in 10 of 16 patients (63%) with transformation of MGUS to MM and 20 of 46 patients (43%) with MGUS who did not progress to MM (odds ratio [OR], 2.2; 95% confidence interval [95% CI], 0.7–7.0; p=0.15). In MM patients who received autologous stem cell transplantation (ASCT), the overall survival was similar among 3 genotype groups. However, in patients who did not received ASCT, patients with IL-10-592A/C and C/C genotype had shorter overall survival compared with patients with IL-10-592A/A genotype (median survival, 32 months vs. not reached).Conclusion: It is reported that IL-10-592 A/C and C/C genotype are high producer of IL-10. Our results suggested that the IL-10-592 A/C and C/C genotype was not associated with the susceptibility to MM, however associated with poor prognosis in MM patients who did not receive ASCT. In addition, IL-10-592 A/C and C/C genotype may contribute to transformation of MGUS to MM. According these data, IL-10 may be implicated in the progression of MM and MGUS, and SNPs of IL-10 is one of prognostic factors in patients with MGUS and MM.

Gene mapping and expression analysis of 16q loss of heterozygosity identifies WWOX and CYLD as being important in determining clinical outcome in multiple myeloma

AbstractWe performed fluorescent in situ hybridization (FISH) for 16q23 abnormalities in 861 patients with newly diagnosed multiple myeloma and identified deletion of 16q [del(16q)] in 19.5%. In 467 cases in which demographic and survival data were available, del(16q) was associated with a worse overall survival (OS). It was an independent prognostic marker and conferred additional adverse survival impact in cases with the known poor-risk cytogenetic factors t(4;14) and del(17p). Gene expression profiling and gene mapping using 500K single-nucleotide polymorphism (SNP) mapping arrays revealed loss of heterozygosity (LOH) involving 3 regions: the whole of 16q, a region centered on 16q12 (the location of CYLD), and a region centered on 16q23 (the location of the WW domain-containing oxidoreductase gene WWOX). CYLD is a negative regulator of the NF-κB pathway, and cases with low expression of CYLD were used to define a “low-CYLD signature.” Cases with 16q LOH or t(14;16) had significantly reduced WWOX expression. WWOX, the site of the translocation breakpoint in t(14;16) cases, is a known tumor suppressor gene involved in apoptosis, and we were able to generate a “low-WWOX signature” defined by WWOX expression. These 2 genes and their corresponding pathways provide an important insight into the potential mechanisms by which 16q LOH confers poor prognosis.

Melphalan-induced DNA damage in vitro as a predictor for clinical outcome in multiple myeloma

As new therapeutic options for multiple myeloma (MM) emerge, identification of biological markers which could predict clinical response to standard treatment with high-dose melphalan (HDM) supported by autologous stem cell transplantation (ASCT) becomes more important. Melphalan-induced damage formation and repair of monoadducts and interstrand cross-links in the p53 gene were studied in peripheral blood mononuclear cells obtained from 32 patients prior to therapy. The same studies were performed in the peripheral blood cells of these patients immediately after subsequent HDM administration. Clinical response and time to progression were correlated with molecular endpoints obtained in vitro. Values for all molecular end-points examined in vitro were highly correlated with the respective in vivo results within individual patients. All in vitro end-points indicative of increased DNA damage and slower repair capacity were predictive of a favorable response to HDM; the area under the curve of total adducts (AUC-TA) had the highest predictive ability. Using the cut-off value of 736 adducts/10(6) nucleotides x h for the AUC-TA, the positive predictive value for clinical response to HDM was 100%. Moreover, patients with an AUC-TA equal to or higher than this cut-off value had significantly longer times to progression than had patients with an AUC-TA lower than the cut-off value (hazard ratio 0.19; 95% confidence intervals 0.06 to 0.60). An in vitro assay to quantify melphalan-induced p53-specific damage formation/repair can be used to select those patients with MM who are more likely to benefit from HDM supported by ASCT.

Genomic Instability in Multiple Myeloma: Inducible Transfectants Provide a Model To Define the Role of RHAMM and Centrosome/Mitotic Spindle Stability in Myelomagenesis.

In this study we describe stably transfected cells expressing RHAMM, the receptor for hyaluronan (HA) mediated motility, under the control of a tetracycline-inducible promoter. We created this model system to determine the potential for RHAMM to promote genomic instability in multiple myeloma (MM), a B-lineage cancer characterized by malignant plasma cells in the bone marrow. MM cells harbor extensive genetic abnormalities, and work in our lab has shown that centrosome abnormalities are present in MM, suggesting a link between the two. RHAMM is a multifunctional protein involved in HA mediated cell motility, cytoskeletal dynamics, and most recently shown by Maxwell et al. in our lab, centrosome and mitotic spindle stability (Mol Biol Cell vol. 14, 2262–2276). The latter studies have revealed that RHAMM dysregulation correlates with mitotic abnormalities that may give rise to aneuploidy, and ultimately to transformation. Furthermore, RHAMM overexpression alone, and together with increasing amounts of its -exon4 splice variant which is unable to bind microtubules, is associated with poor clinical outcome in MM. This suggests that the centrosome/mitotic spindle stabilizing function of RHAMM has real consequences for the malignant clone in MM. In previous work with transient transfection systems, RHAMM overexpression resulted in mitotic arrest, mitotic abnormalities and ultimately apoptosis; this may explain the difficulty in creating stable transfectants expressing RHAMM in an unregulated manner. Using a tetracycline-inducible system, we have identified stably transfected RHAMM-expressing clones, some exhibiting up to forty-fold increase in RHAMM transcripts on induction, as measured by real-time PCR. Induced RHAMM protein was observed as early as 48 hours post-induction by immunofluorescence, in association with the mitotic spindle, the cytoskeleton, the cell membrane, and in a fraction of the population, interphase nuclei. Centrosomal localization of RHAMM was also observed, in most cases after centrosome replication and subsequent migration during prophase. In the induced cells, phenotypes similar to the transient system were observed: a trend towards multipolar and disorganized spindles, multinucleated and apoptotic cells by immunofluorescence, and a dramatic onset of apoptosis as early as 72 hours post-induction as measured by annexin V staining and flow cytometric analysis. More detailed studies characterizing RHAMM overexpressing cells that survive aberrant mitoses are ongoing. By finely controlling the expression of RHAMM in this system, something not easily done in transiently transfected cells, we can assess the effects of incremental increases in RHAMM expression, which may more accurately reflect the events that occur during malignant transformation. We speculate that oncogenesis may involve upregulation of yet to be defined genetic mechanisms that allow tumor cells to escape the apoptotic effects of overexpressed RHAMM and thereby promoting the survival and selection of mitotically abnormal clonal variants having misseggregated chromosomes and increasingly aggressive characteristics. In this way, stably transfected cell lines currently under development will provide relevant model systems to assess the role of RHAMM and associated centrosome, mitotic spindle, and microtubule motor proteins in malignant transformation and progression of MM.

Melphalan-Induced DNA Damage In Vitro as Predictor for Clinical Outcome in Multiple Myeloma.

Introduction: We have previously shown that measuring in vivo DNA adduct formation/repair in the p53 gene, in a readily accessible tissue such as peripheral blood mononuclear cells (PBMC) provides a non-invasive method for evaluating the effectiveness of high-dose melphalan (HDM) in MM. In the present study, we tested the hypothesis that quantification of p53-specific damage formation and repair induced in PBMC by in vitro melphalan treatment before therapy correlates with the respective data obtained in vivo, ie after administration of HDM. Furthermore, we studied whether this in vitro assay can predict outcome after HDM.Patients and Methods: Thirty-two MM patients, with measurable disease, candidates for HDM and ASCT were included in the study. Response and progression were assessed according to the EBMT criteria. Prior to treatment with HDM, PBMC from patients were exposed in vitro to melphalan; subsequently, formation and repair of monoadducts and interstrand cross-links in the p53 gene were measured during the first 24 hours. The same studies were performed in PBMC-derived DNA following HDM administration to the same patients as previously reported (Dimopoulos et al, JCO 2005). Spearman's correlation coefficient was used to assess correlation of in vivo to in vitro parameters in the p53 gene. Clinical response and time to progression were correlated with various molecular end-points using logistic regression and proportional hazards (Cox) models.Results: Twenty-three patients (72%, responders) achieved complete (n=9) or partial response (n=14). Nine patients (28%, non-responders) did not have tumor reduction after HDM. During the follow-up period (median 15.4 months, range 2.4 to 26 months), 15 patients (47%) experienced disease progression.Individual in vivo and in vitro values were, in general, highly correlated for all DNA adducts. The strongest correlation was observed for the Area Under the Curve of total adducts (AUC-TA, Spearman correlation coefficient: 0.93).All in vitro molecular end-points indicative of increased DNA damage and slower repair capacity were predictive of a favorable response to HDM whilst AUC-TA had the highest predictive ability. Using the cut-off value of 736 adducts/106nucleotidesxh for AUC-TA, the predictive value for clinical response to HDM was 100%. Moreover, patients with AUC-TA equal to or greater than this cut-off value had significantly longer time to progression than patients with a lower AUC-TA (hazard ratio 0.19, 95% confidence intervals 0.06 to 0.60).Conclusion: We found that the extent of p53-specific damage formation/repair in PBMC from MM patients following in vitro exposure to melphalan correlates with the respective results obtained in vivo, i.e. after treatment with HDM, and is of value in predicting clinical response and progression free survival. Thus, this in vitro assay can be used to select those patients with MM who are more likely to benefit from HDM.

P53 Gene Deletion Detected by Fluorescence In Situ Hybridization Is an Adverse Prognostic Factor for Patients with Multiple Myeloma Following Autologous Stem Cell Transplantation.

We investigated the relevance of p53 deletions to the clinical outcome of multiple myeloma (MM) patients treated with high-dose chemotherapy and autologous stem cell transplantation. Hemizygous p53 gene deletions were detected by cytoplasmic Ig-enhanced interphase fluorescence in situ hybridization (cIg-FISH) in 10 of 105 (9.5%) patients studied. p53 deletions were associated with higher serum calcium (p=0.0062) and creatinine (p=0.013) levels but there were no association with patient age, gender, β-2 microglobulin, C-reactive protein, hemoglobin, albumin, bone lytic lesions, or immunoglobulin isotype. There were no association of p53 deletions with chromosome 13q deletions, translocation t(11;14) or t(4;14). The overall response rates were similar in patients with and without p53 deletions (67% vs 71%). However, patients with p53 deletions had significantly shorter progression free (median 7.9 vs. 25.7 months, p=0.0324) and overall survival (median 14.7 vs. 48.1 months, p=0.0008) than patients without a p53 deletion. A multivariate analysis confirmed p53 deletion was an independent prognostic factor predicting shortened progression free (p=0.0009) or overall survival (p=0.0002) in myeloma patients after high-dose chemotherapy and autologous stem cell transplantation.

Autologous blood cell transplantation in multiple myeloma: impact of CD34+ cell selection with long follow-up.

Positive CD34(+) selection to purge blood cell harvests is one way to attempt to reduce the high relapse risk after high-dose chemotherapy (HDT) supported by autologous blood cell transplantation (ABCT) in patients with multiple myeloma (MM). Until recently, however, the impact of CD34(+) selection, if any, on long-term clinical outcome in MM has remained obscure. We have analyzed engraftment kinetics, response to HDT, progression-free survival (PFS), and overall survival (OS) for 64 consecutive MM patients who have been treated with up-front HDT plus ABCT at our institution between 1993 and 1998. Nonrandomized comparisons were made between transplants with unselected (39 patients) and CD34(+)-selected (25 patients) grafts. The engraftment kinetics, need of blood product support, discharge time from hospital, and response to HDT were similar for both unselected and selected transplants. The median PFS was also similar (26 and 30 months, respectively) for the both groups. With a median follow-up time for the survivors of 67.5 months, the median OS (78 and 75 months, respectively) did not differ between transplants with unselected and selected grafts. In conclusion, this nonrandomized study suggests that positive CD34(+) selection has no beneficial impact on long-term outcome of patients with MM.

High-dose chemotherapy and autologous CD34-positive blood stem cell transplantation for multiple myeloma in an HIV carrier

The epidemiology and clinical outcome of multiple myeloma in human immunodeficiency virus (HIV)-positive patients is poorly documented. There are uncertainties concerning the optimal management of this rare disorder. We report on the use of myeloablative chemotherapy with autologous stem cell transplantation in an HIV-positive patient with multiple myeloma.

Early lymphocyte recovery predicts superior survival after autologous hematopoietic stem cell transplantation in multiple myeloma or non-Hodgkin lymphoma

AbstractAutologous stem cell transplantation (ASCT) improves survival in patients with previously untreated multiple myeloma (MM) and relapsed, chemotherapy-sensitive, aggressive non-Hodgkin lymphoma (NHL). Lower relapse rates seen in allogeneic stem cell transplantation have been related to early absolute lymphocyte count (ALC) recovery as a manifestation of early graft-verus-tumor effect. In ASCT, the relation between ALC recovery and clinical outcomes in MM and NHL was not previously described. This is a retrospective study of patients with MM and NHL who underwent ASCT at the Mayo Clinic between 1987 and 1999. The ALC threshold was determined at 500 cells/μL on day 15 after ASCT. The study identified 126 patients with MM and 104 patients with NHL. The median overall survival (OS) and progression-free survival (PFS) times for patients with MM were significantly longer in patients with an ALC of 500 cells/μL or more than patients with an ALC of fewer than 500 cells/μL (33 vs 12 months,P < .0001; 16 vs 8 months, P < .0003, respectively). For patients with NHL, the median OS and PFS times were significantly longer in patients with an ALC of 500 cells/μL or more versus those with fewer than 500 cells/μL (not reached vs 6 months, P < .0001; not reached vs 4 months,P < .0001, respectively). Multivariate analysis demonstrated day 15 ALC to be an independent prognostic indicator for OS and PFS rates for both groups of patients. In conclusion, ALC is correlated with clinical outcome and requires further study.