Factor In Multiple Myeloma Research Articles

Interlaboratory Analytical Validation of a Next-Generation Sequencing Strategy for Clonotypic Assessment and Minimal Residual Disease Monitoring in Multiple Myeloma.

Minimal residual disease (MRD) is a major prognostic factor in multiple myeloma, although validated technologies are limited. To standardize the performance of the LymphoTrack next-generation sequencing (NGS) assays (Invivoscribe), targeting clonal immunoglobulin rearrangements, in order to reproduce the detection of tumor clonotypes and MRD quantitation in myeloma. The quantification ability of the assay was evaluated through serial dilution experiments. Paired samples from 101 patients were tested by LymphoTrack, using Sanger sequencing and EuroFlow's next-generation flow (NGF) assay as validated references for diagnostic and follow-up evaluation, respectively. MRD studies using LymphoTrack were performed in parallel at 2 laboratories to evaluate reproducibility. Sensitivity was set as 1.3 tumor cells per total number of input cells. Clonality was confirmed in 99% and 100% of cases with Sanger and NGS, respectively, showing great concordance (97.9%), although several samples had minor discordances in the nucleotide sequence of rearrangements. Parallel NGS was performed in 82 follow-up cases, achieving a median sensitivity of 0.001%, while for NGF, median sensitivity was 0.0002%. Reproducibility of LymphoTrack-based MRD studies (85.4%) and correlation with NGF (R2 > 0.800) were high. Bland-Altman tests showed highly significant levels of agreement between flow and sequencing. Taken together, we have shown that LymphoTrack is a suitable strategy for clonality detection and MRD evaluation, with results comparable to gold standard procedures.

The Effects of Vitamin D Level on Bone Lesions and Prognostic Factors in Multiple Myeloma

The Effects of Vitamin D Level on Bone Lesions and Prognostic Factors in Multiple Myeloma

The Exosomes-Derived EGFR Ligand Amphiregulin (AREG) Is a New Pro-Osteoclastogenic Factor in Multiple Myeloma

Growing evidence indicates the critical role of the microvesicles to sustain multiple myeloma (MM) cell viability, survival and drug resistance into the bone marrow (BM) microenvironment. Recently it has also been suggested that MM cell-derived exosomes have a role in the induction of osteoclasts (OCs) differentiation and activity. The mechanism by which exosomes might be involved in MM-induced osteoclastogenesis is not known and was investigated in this study focusing on the possible role of Epidermal growth factor receptor (EGFR) ligands because it has been previously published their involvement in osteolytic bone metastasis by breast and lung cancer.Thus the aim of the study was to investigate the presence of EGFR ligands in exosomes derived from different MM cell lines and primary CD138+ cells and to determine whether exosome-enclosed EGFR ligands are able to modulate the tumor microenvironment by affecting the function of OCs.We firstly analyzed the expression of EGFR ligands at mRNA level on plasmacells (PCs) from patients with different monoclonal gammopathies (11 monoclonal gammopathy of undetermined significance, 133 MM patients at the diagnosis, 9 primary plasma cell leukemia) in a published dataset (accession number GSE16122) and we found that CD138+ cells expressed Amphiregulin (AREG) mRNA at high but variable levels among MM patients. Consistently, in a different dataset (GSE2658) of PCs, it has been previously reported that, among the EGFR ligands, AREG is significantly over-expressed by MM cells as compared to normal PCs (GSE5900).Secondly we isolated exosomes by ultracentrifugation, from MM1S cell line and from BM plasma samples of 4 patients with active MM, and were characterized by western blot analysis of the exosome marker TSG101. We found that AREG was specifically enriched in exosomes derived from both MM1S and plasma samples of 3 patients, as confirmed by its absence in the exosome-deprived conditioned medium of MM1S cell line.In order to test whether MM-exosomes could potentiate MM-induced osteoclastogenesis through the activation of the EGFR pathway, primary CD14+ monocytes purified from peripheral blood (PB) of 3 healthy donors and a murine cell line (RAW264.7) were used as OC models. Cells were treated with (i) exosomes (25 mg/ml) from both MM1S and plasma samples, pre-treated or not with anti-AREG neutralizing antibodies (Abs) (20 mg/ml) or (ii) with recombinant human (rh) AREG (20 mg/ml). Interestingly we found that MM1S exosome treatment induced the activation of EGFR as showed by the increase EGFR phosphorylation in RAW 264.7 cell line; this effect was reverted in the presence of anti-AREG neutralizing Ab. In addition we found that the six days treatment with MM1S exosomes induced a significant increase in the mRNA expression level of SNAIL, a downstream target of EGFR, both in RAW 264.7 and PB CD14+. The presence of anti-AREG neutralizing reverted this effect. Finally we showed a significant increased of the expression of OC specifics marker such as Cathepsin K (CTSK), Matrix Metalloproteinases 9 (MMP9) and Tartrate-resistant Acid Phosphatase (TRAP), both in RAW 264.7 and PB CD14+ cells after treatment with MM-derived exosomes as compared to the control. The pro-osteoclastogenic effect of MM-derived exosomes was significantly abrogated by exosome pre-treatment with anti-AREG neutralizing Ab suggesting a possible direct effect of MM-exosome derived AREG on OC differentiation. However we also performed treatment of human pre-osteoblasts (PreOBs), obtained from mesenchymal stromal cells, with MM-derived exosomes in the presence or the absence of anti AREG Ab hypothesizing an indirect pro-osteoclastogenic effect mediated by the inhibition of osteoprotegerin (OPG) production by PreOBs.In conclusion, our data indicate that the EGFR ligands are packed into MM-derived exosomes and involved in OCs differentiation thus highlighting the role of AREG as a potential new player in MM-induced bone resorption. DisclosuresNo relevant conflicts of interest to declare.

The Effect of Bortezomib on Renal Dysfunction in African American Patients with Multiple Myeloma

Introduction -Renal dysfunction (RD) is a major negative prognostic factor in multiple myeloma (MM). Approximately 50% of patients have RD throughout the course of their disease, which is associated with a more aggressive clinical course, poorer quality of life, and shortened overall survival. Bortezomib, a potent proteasome inhibitor, has shown significant anti-myeloma activity and is known to have a protective renal effect. In addition, it is well known that African Americans (AA) are twice as likely to be diagnosed with MM compared to Caucasians and tend to have worse outcomes. At our cancer center, which is in a large urban hospital, nearly 85% of MM patients are AA. To date, there has been no study specifically looking at the reversibility of RD in this population. We evaluated the effectiveness of bortezomib on RD in AA patients with MM in a large urban hospital.Methods -We conducted a retrospective analysis to investigate the outcome of bortezomib based therapy in 51 AA patients diagnosed with MM and RD from 2004-2015, including 4 cases requiring hemodialysis. Renal dysfunction was defined as Cr ³ 2.0 mg/dL or GFR < 60 mL/min/1.73m2. Patients required at least 3-6 months of continuous treatment with a bortezomib based regimen to be eligible for analysis. Laboratory data was collected prior to initiation of treatment, and again at 3 months and 6 months. Both newly diagnosed and relapsed or refractory patients were included.Results -Approximately 75% of patients treated with bortezomib were > 65 years old, with an equal distribution of males and females. At presentation, 80% had anemia (Hb<10 g/dL), 14% hypercalcemia (Ca>11 mg/dL), 37% elevated LDH, 61% elevated B2 microglobulin. The majority of patients had normal risk cytogenetics and 33% were ISS stage III. Myeloma subtype was IgM 65%, IgA 16%, IgM 2%, light chain only 16%. Sixty percent were kappa light chain subtype. The median M spike was 2.54 (range 0.5-16), creatinine 2.41 mg/dL (range 1.1-10.48), GFR 38 mL/min/1.732 (range 6-60). Treatment was bortezomib based in 100% patients: 6% had bortezomib, 45% bortezomib/dexamethasone (VD), 22% VD/cyclophosphamide (VCD), 12% VD/lenalidomide (VRD), 12% VD/melphalan (VMP), 2% VD/thalidomide (VTD), 2% VD/doxorubicin (PAD). A partial response or better was seen in 55% of patients by month 3 and 63% of patients by month 6.Improvement of RD was observed in 85% of patients by month 3. The average creatinine improved by approximately 24.5% (p<0.001), GFR improved by 52.6% (p<0.001). A plateau effect was noticed by month 6, as creatinine and GFR improved by 19.5% and 44.7%, respectively. Newly diagnosed patients had a greater reversal of RD compared to relapsed/refractory disease (p=0.032). None of the 4 patients who began hemodialysis were able to discontinue this therapy.Conclusion -A statistically significant improvement in RD was observed in AA patients with MM based on Cr and GFR treated with a bortezomib based regimen. The greatest response was seen in the first 3 months of therapy which plateaued by month 6. These differences were magnified in de novo compared to relapsed/refractory disease. No patients were able to discontinue hemodialysis if already initiated prior to starting treatment. Bortezomib is a safe and effective drug in the subset of AA patients with impaired renal function. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Age Related Distribution of Cytogenetic Abnormalities in Multiple Myeloma

Introduction . Cytogenetic abnormalities (CA) detected by iFISH are among the most powerful prognostic factors in multiple myeloma (MM). With the advent of an unpreceded therapeutic armamentarium during the last years, a thoroughly assessment of individual patients characteristics is necessary in order to choose the best therapy. Among the former, age is an important biologic feature that stratifies patients with regard to treatment intensity.Aims . To study the distribution of individual CA by iFISH according to different age groups and to evaluate the relationship between age and different cytogenetic profiles.Materials and methods . We retrospectively evaluated 1116 patients (pts) analyzed in our laboratory between 01/2010 and 12/2016 for whom baseline cytogenetics by iFISH was available. iFISH was carried out on CD138 enriched plasma cells combined with immunofluorescent detection of light chain (LC) restricted plasma cells. The following CA were considered: gain(1q21), gain(9q34), del(13q14), del(17p13), t(4;14), t(11;14), t(14;16). Commercially available DNA probes were used according to manufacturer protocols (MetaSystems, Vysis). In house cutoff levels of 15% and 17% were set for chromosomal imbalances and IgH translocations respectively. Patients were stratified into 3 age groups: 1st group ≤ 45 years (y), 2nd group > 45y and ≤ 65y and 3th group > 65y. High risk cytogenetics (HRC) were defined according to IMWG criteria as at least one of the following by iFISH: del(17p), t(4;14) and t(14;16). Pairwise comparisons between subgroups were performed by the Mann-Whitney or Kruskal Wallis test for continuous variables and by Fisher's exact test for categorical variables. All statistical analyses were conducted in R, version 3.0.1.Results . The 1st group comprised 92 (8%) pts, the 2nd 581 (52%) pts and the 3rd 443 (40%) pts. The t(4;14) was detected in 109 (9.8%) pts with higher prevalence in the 2nd and 3rd groups (7.6% vs 10.3% vs 9.5%, p=0.67). The t(11;14) was detected in 198 (18%) pts with a higher prevalence in younger pts (26% vs 18 % vs 16%, p=0.15); age density plots showed two prevalence peaks at 45y and 65y respectively (Fig 1). The t(14;16) was identified in 26 pts (2.3%) and occurred more frequent under 65y (2.7% vs 4.2% vs 1.6%, p=0.11). Gain(9q) was identified in 365 (32%) of 781 evaluable patients occurring less frequently under the age of 45y (22% vs 35% vs 31%, p=0.4). Gain(1q) was detected in 249 (22%) pts with a trend towards higher prevalence in pts over 45y (14% vs 23% vs 23%, p=0.09). Del(17p) was detected in 153 pts (14%) slightly more frequent in the 2nd age group (13% vs 15% vs 12%, p=0.4). Del(13q) was more frequent in the 2nd group (32% vs 42% vs 37%, p=0.12).Next, we analyzed the distribution of HRC according to age category and identified 36 (21%) pts in the 1st group, 188 (26%) pts in the 2nd group and 119 (22%) pts in the 3rd group (p= 0.21). If gain(1q) was added to the HRC profile, the distribution of the HRC between groups differed significantly (27% vs 40% vs 34%, p=0.012).For the entire cohort, we further looked how t(4;14) and t(11;14) co-occur with gain(1q) and del(17p). Overall, 38% of the patients with t(4;14) had a gain(1q) (OR 2.8, p< 0.001). Conversely, no significant relation was detected for t(11;14) and for both translocations and del(17p). An inverse relation was found for del(17p) and gain(1q), with only 22% of pts with del(17p) harboring gain(1q) (OR 0.59, p=0.03). An interesting observation was the distribution of the k and λ LC across different CA. We found a significantly higher prevalence of k LC in MM with t(11;14) (60%, p=0.015), gain(1q) (54%, p=0.001) and HRC (67%, p<0.001). Regarding age, no significant difference was identified for the frequency of one type LC or another between age groups (p=0.978).Conclusion. In line with previous data,our study on a large unselected patient cohort suggests an age dependent distribution of CA. Though not reaching statistical significance, t(11;14) tends to occur more often in younger pts. The HRC profile is found more frequently in pts between 45y and 65y . Adding gain(1q) to the HRC panel delineates this group more clearly. Still, the prognostic value of 1q in the era of novel agents is controversial and might be related to the strong association with t(4;14). [Display omitted] DisclosuresKnop:Takeda: Consultancy.

Maintenance Treatment with Lenalidomide for Multiple Myeloma Increases the Proportion of MRD Negative (Flow-/PET-CT-) Patients

IntroductionLenalidomide maintenance therapy in Multiple Myeloma has been used in order to prolong the Progression-Free Survival (PFS) obtained with any induction therapy through the depletion of residual tumor burden. In this way, it is well established the value of Minimal Residual Disease (MRD) assessed by flow cytometry (FCM) as an independent prognosis factor in Multiple Myeloma. Similarly, patients who become PET-CT negative (when previously they have proved lesions) have better survival outcomes; in fact, this has recently been accepted as a new response criterion.However, the available data about the complementary use of both techniques in terms of prognosis are limited. The aim of this study is to analyze the prognostic impact of achieving negative residual disease by FCM and PET-CT during Lenalidomide maintenance therapy.MethodsWe retrospectively selected 87 Multiple Myeloma patients from 3 Spanish hospitals (Hospital 12 de Octubre, Hospital Virgen de las Nieves and Hospital Ramón y Cajal). Main selection criterion was to start Lenalidomide maintenance therapy between 2008-2017; the previous induction therapy was heterogeneous. 75% of included patients had previously received an autologous stem cell transplant. We collected data about baseline variables, clinical and biological parameters, therapy administered and FCM and PET-CT assessment at diagnosis, post-induction and during maintenance. Statistical analysis was realized with SPSS 21.0 version (SPSS, Inc., Armonk, NY).ResultsResponse at the beginning of maintenance was VGPR or CR in 78% of patients and 48,3% were MRD-. Initial PET-CT was positive in 31%. After a median of 21 Lenalidomide cycles, 32% of patients with initial MRD+ achieve MRD-; meanwhile, 48,1% of patients with initial PET-CT+ become negative.When we jointly assessed FCM and PET-CT results during maintenance therapy (49 patients had been studied by both techniques), we detected a significant difference in terms of PFS between patients that achieve combined PET-/FCM- and the other groups (median PFS not reached vs 32 months, respectively; p<0,0001) (Fig.1). We also found a trend to longer OS in patients PET-/FCM- (4-year OS 100% vs 83%; p=0,053). Patients with standard-risk cytogenetics were more frequently PET-/FCM- than in the high-risk cytogenetics group (31,8% vs 5,6%; p=0,002); nevertheless high-risk cytogenetics patients that achieve PET-/FCM- (n=3) also had prolonged PFS (4-year PFS 100%).ConclusionLenalidomide maintenance therapy increases the proportion of patients that achieve combined PET-/FCM-. Both techniques are complementary and their combination allows us to identify a subset of PET-/FCM- patients with very good prognosis and PFS outcomes significantly superior than the other patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

CD200 Is a Potent New Growth Factor in Multiple Myeloma through IGF-1R Interaction

Multiple myeloma (MM) is the second most common hematologic malignancy characterized by the accumulation of clonal plasma cells within the bone marrow.We previously identified that CD200 is expressed in Multiple Myeloma Cells (MMCs) of 78% of newly MMdiagnosed patients and this expression is associated with a bad prognosis. CD200 is a type I immunoglobulin superfamily transmembrane glycoprotein that is expressed by various cell types including B cells and T cells. In tumors cells, interaction of CD200 with its known receptor CD200R, inhibits T-cell mediated immune response and induces immunosuppressive responses. However, the role of CD200 in tumorigenesis is poorly understood. Recently, a study shown that CD200 can induce neuritogenesis and promote neuronal survival of primary neurons through interaction and activation of the fibroblast growth factor receptor.Here, we investigated for the first time the role of CD200 in MM cell biology. First, we identified that CD200 protein expression is present only in 3 out of 9 Human Myeloma Cell lines (HMCLs). Then, we confirmed that CD200 protein is strongly expressed in MMCs of 73% of the 35 previously untreated MM patients and that CD200 is never expressed in the normal plasma cell counterparts.CD200 overexpression using lentiviral vector significantly increased HMCLs cell growth in a serum free culture medium (SYN-H) compared to GFP overexpression (fold increasing: 1.6 and 1.4 at day 4; 2.5 and 2.1 at day 7 for LP1 and XG1 respectively). Furthermore, CD200 overexpression results in significant increasing of the number of colonies for HMCLs CD200positive compared to HMCLs CD200negative in clonogenic assays (4.3 fold and 13.1 fold for LP1 and XG1 respectively, p<0.001). We confirmed also the growth advantage linked to CD200 overexpression in coculture model. These effects are significantly inhibited by a monoclonal antibody (MoAb) against CD200 compared to treatment with a no-relevant anti-IgG1. We also confirmed the significant inhibition of proliferation with the anti-CD200 MoAb using clonogenic assays. The anti-CD200 MoAb has no effect on the GFP transduced HMCLs.To investigate the implication of CD200R in CD200-induced MM cell growth, inducible CD200R depletion was analyzed in CD200positive and CD200negative, using lentiviral vectors. After doxycycline addition, the shCD200R reduced CD200R expression by 95-100% but had no significant effects on the proliferation advantage mediated by CD200 demonstrating that the growth advantage supported by CD200 overexpression is independent of CD200R.Thus, to investigate the possibility of another receptor activated by CD200 interaction, we added different essential MM growth factors to the serum free medium. Addition of fetal calf serum, IGF1 or insulin in SYN-H medium abrogated the growth advantage provided by CD200 overexpression in HMCLs. These data suggest that CD200 could act as a growth factor through interaction and activation of IGF1R. In addition, overexpression of CD200 in a IGF-1R negative XG12 HMCL did not stimulate its cell growth or clonogenic activity. Furthermore, anti-IGF-1R monoclonal antibody completely abrogated the CD200-dependent growth activity at day 4 and at day 7 in LP1CD200positive cell line compared to non-relevant antibody. The anti-IGF-1R MoAb has no effect on control LP1GFPpositive cell line cultured in serum free culture medium.In order to identify a direct interaction between CD200 and IGF-1R in serum free culture conditions, IGF-1R immunoprecipitation in denaturing conditions was performed at day 4 using LP1GFP and LP1CD200 cell lines. CD200 and IGF-1R interaction was identified by mass spectrometry and western-blotting.According to these data, MM patients with CD200high and IGF1Rhigh gene expression have a poor prognosis (OS) compared to patient with only CD200high or IGF1Rhigh expression (P=0.03, 52.7 vs 61.9 months in HM series; and P=0.02, 58.9 vs 68.1 months in TT2 series) and compared to patients with CD200low and IGF1Rlow gene expression (P=0.002, 52.7 vs 71.6 months in HM series; and P=0.01, 58.9 vs 70.2 months in TT2 series). Same results are observed for EFS.Altogether, these data demonstrated a new role of CD200 as a MM growth factor through interaction with IGF1R. Our results suggest that CD200 and IGF1R inhibition by monoclonal antibodies could represent a promising strategy in MM. DisclosuresCartron:Sanofi, BMS, Jansen, celgene, Roche, Gilead: Equity Ownership; Celgene: Consultancy, Employment; Roche: Consultancy, Equity Ownership, Honoraria, Research Funding. Hose:Sanofi: Research Funding; Takeda: Membership on an entity's Board of Directors or advisory committees; EngMab: Research Funding.

High Expression of the Resistant Factor YY1 and Low Expression of the RKIP Chemosensitizing Factor in Multiple Myeloma: Delineation of Several Crosstalk Pathways That Regulate the Expression of These Factors

Background: We have reported that multiple myeloma (MM) expresses high levels of the transcription (oncogenic) factor YY1, which regulates cell survival, proliferation, and resistance to both immuno- and chemotherapeutic drugs.1 Inhibition of YY1 sensitizes the tumor cells to cell death/apoptosis to cytotoxic drugs. In contrast, we have also reported that MM expresses very low levels of Raf kinase inhibitor protein (RKIP) and/or high levels of inactive phosphorylated RKIP.2 Overexpression of RKIP or de-phosphorylation of phosphorylated RKIP sensitized drug-resistant MM to drug-induced apoptosisHypothesis: The inverse relationship between YY1 and RKIP expression levels suggested that the two factors may be regulated through crosstalk pathways.Methods: Analysis of the literature revealed the presence of five crosstalk pathways that link RKIP and YY1.Results: The crosstalks consisted of the followings: (1) The NF-κB/YY1/Snail/RKIP loop. In the presence of RKIP, the NF-κB pathway is inhibited and consequently, the NF-κB targets YY1 and Snail are also inhibited. In turn, inhibition of the RKIP repressor Snail resulted in the upregulation of RKIP expression, all of which led to sensitization of drug-resistant tumor cells. (2) The p38 MAPK/RKIP/GSK3β/Snail/YY1 loop. In the presence of RKIP expression, the p38 MAPK-mediated phosphorylation of GSK3β is inhibited and results in the phosphorylation of Snail and its degradation, leading to the de-repression of RKIP expression and inhibition of YY1. (3) The RKIP/Smurf-2/YY1/Snail loop. SMAD ubiquitin regulatory factor 2 (Smurf-2) is an E3 ubiquitin ligase that degrades YY1. In tumor cells, there is low expression of Smurf-2 and, thus, little inhibition of YY1 with high Snail expression in the presence of low expression of RKIP. In the presence of high levels of Smurf-2, YY1 is inhibited, resulting in the inhibition of Snail and de-repression of RKIP. (4) The RKIP/MAPK/Myc/Let-7/HMGA2/Snail/YY1 loop. Let-7/miR98 suppresses Ras and inhibits the MAPK signaling pathway. In the absence of RKIP, the Raf/MEK1-2 pathway is activated and downstream Myc is expressed. In turn, Myc-induced Lin-28 inhibits Let-7, and leads to upregulation of HMGA2. Consequently, HMGA2 activates Snail, in addition to its regulation by YY1. In contrast, in the presence of RKIP, the Raf/MEK pathway is inhibited and there is downstream inhibition of its targets Myc, Lin-28, and HMGA2, leading to an inhibition of Snail and de-repression of RKIP. (5) The RKIP/GPCR/STAT3/miR-34/YY1 loop. In tumor cells expressing low levels of RKIP, there is no efficient inhibition of GPCR and MAKP signaling pathways. Hence, there is a constitutive activation of oncogenic STAT3 that inhibits the tumor suppressor miR-34. Thus, low miR-34 levels de-repress YY1 translation and facilitate its effects on the survival and the resistance of tumor cells to cytotoxic drugs.Conclusion and Implications: The above YY1/RKIP gene signatures might predict the tumor expanding potential and overall aggressiveness and their detriments that contribute to tumor regression. Targeting YY1 inhibition or RKIP induction via interference of the above crosstalk pathways may result in synergistic activity in combination with conventional treatments.References1 Bonavida B, Kaufhold S. Prognostic significance of YY1 protein expression and mRNA levels by bioinformatics analysis in human cancers: a therapeutic target. Pharmacol Ther. 150:149-68, 2015.2 Baritaki, S, Huerta-Yepez, S, Cabrava-Haimandez, M, Sensi, M, Canevari, S, Libra, M, Penichet, M, Chen, H, Berenson, JR, Bonavida, B. Unique Pattern of Overexpression of Raf-1 Kinase Inhibitory Protein in Its Inactivated Phosphorylated Form in Human Multiple Myeloma. Forum on Immunopathological Diseases and Therapeutics, 2: 179-188, 2011. DisclosuresNo relevant conflicts of interest to declare.

Molecular Characterisation of TP53 Aberrations in 1,777 Myeloma Trial Patients

Molecular Characterisation of TP53 Aberrations in 1,777 Myeloma Trial Patients

Whole-body diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient values as prognostic factors in multiple myeloma.

Multiple myeloma (MM) is a neoplasm of the B lymphocytes characterized by the uncontrolled proliferation of a plasmocyte clone. Magnetic resonance imaging (MRI) remains the most sensitive and specific imaging method for the detection of bone marrow infiltration, before macroscopic bone changes are visible, with evidence that the detection rate and overall performance of MRI could be enhanced by applying diffusion-weighted imaging (DWI). The aim of our research was to evaluate whether measuring apparent diffusion coefficient (ADC) values in newly diagnosed patients with MM could be a prognostic factor for the course of the disease and to ascertain whether there is any correlation with other prognostic factors in MM. A retrospective study was performed on a group of 32 patients with newly diagnosed MM that underwent at least two whole-body (WB)-MRIs; one before and one after induction therapy. Patients with advanced stage of disease showed an increased ADC value: Stage 2 vs. stage 1 (1.162 vs. 0.289, P=0.033), respectively, stage 3 vs. stage 1 (0.867 vs. 0.289, P=0.041). In addition, ADC values were inversely correlated with survival time: r=-0.641, P<0.001. According to the multivariate linear regression model, we observed that for every point of ADC value (before treatment) the survival was decreased/reduced by 14.5 months. Moreover, bortezomib therapy predicted an increase in the survival length/duration by 7.9 months. Our regression equation proved to be a good fit for the model, explaining 57.8% of survival duration (adjusted R2=0.578). In conclusion, the negative prognostic factors associated with WB-MRI are represented by high ADC values before treatment (for every point of ADC the survival was decreased by 14.5 months) and focal/diffuse marrow involvement.

Carfilzomib-based induction/consolidation with or without autologous transplant (ASCT) followed by lenalidomide (R) or carfilzomib-lenalidomide (KR) maintenance: Efficacy in high-risk patients.

8002 Background: Cytogenetic abnormalities (CA) are one of the most powerful prognostic factors in multiple myeloma (MM). In the FORTE study, carfilzomib-lenalidomide-dexamethasone induction/consolidation with ASCT (KRd_ASCT) significantly improved progression-free survival (PFS) vs KRd without ASCT (KRd12, HR 0.64) or carfilzomib-cyclophosphamide-dexamethasone (KCd) plus ASCT (KCd_ASCT, HR 0.53). KR maintenance significantly improved PFS vs R (HR 0.63). Methods: MM patients (pts) were randomized to KRd_ASCT vs KCd_ASCT vs KRd12 and, thereafter, to KR vs R maintenance. Subgroup analyses according to FISH evaluated the impact of each single high-risk (HiR) CA [del17p, t(4;14), t(14;16), del1p and 1q gain (3 copies) or amp1q (≥4 copies)] and that of combined CA, defining HiR by the presence of ≥1 HiR CA and double-hit (DH) by the presence of ≥2 HiR CA. Pts negative for all the HiR CA were considered at standard risk (SR). The primary objective was the impact of treatment on PFS according to pt risk. Results: 396 out of 474 enrolled pts were included in the analysis with complete FISH data: 243 HiR, 105 DH and 153 SR. Among HiR pts, 60 had del17p, 65 t(4;14), 20 t(14;16), 44 del1p, 126 1q gain and 49 amp1q. SR pts benefited from intensification with KRd_ASCT vs KRd12 (HR 0.47, p = 0.05) and KCd_ASCT (HR 0.38, p = 0.01), with a 4-year PFS of 80%, 67% and 57%, respectively. In HiR pts, KRd_ASCT improved PFS vs KRd12 (HR 0.6, p = 0.04) and KCd_ASCT (HR 0.57, p = 0.01), with a 4-year PFS of 62%, 45% and 45%, respectively. The advantage with KRd_ASCT vs KRd12 (HR 0.53, p = 0.07) and KCd_ASCT (HR 0.49; p = 0.03) was also observed in DH pts (4-year PFS 55%, 31% and 33%, respectively). Analyses by single CA were limited by the small number of pts in each subgroup, but a trend towards a PFS benefit from KRd_ASCT vs KRd12 was seen in pts with del17p (HR 0.61, p = 0.3), t(4;14) (HR 0.59, p = 0.2) and 1q gain (HR 0.45, p = 0.02). In pts with del1p, KRd_ASCT (HR 0.24, p = 0.06) and KRd12 (HR 0.33, p = 0.09) showed superiority over KCd_ASCT, while amp1q pts had the worst outcome regardless of treatment (KRd_ASCT vs KCd_ASCT, HR 1.16, p = 0.73; KRd12 vs KCd_ASCT, HR 1.34, p = 0.45). KR improved PFS vs R in SR (3-year PFS 90% vs 73%, HR 0.42, p = 0.06), HiR (3-year PFS 69% vs 56%, HR 0.6, p = 0.04) and DH pts (3-year PFS 67% vs 42%, HR 0.53, p = 0.1). Despite the small subgroups, a beneficial trend with KR vs R was observed in pts with del17p (HR 0.59, p = 0.37), t(4;14) (HR 0.59, p = 0.3), 1q gain (HR 0.54, p = 0.07) and del1p (HR 0.23, p = 0.08), while amp1q pts showed the worst outcome and no benefit from KR vs R (HR 0.83, p = 0.7). Conclusions: KRd_ASCT and KR maintenance are highly effective in SR and also in HiR and DH pts, with impressive 4-year PFS from diagnosis (KRd_ASCT: HiR 62%, DH 55%) and 3-year PFS from maintenance (KR: HiR 69%, DH 67%), thus supporting their use in HiR pts, who represent an unmet medical need. Clinical trial information: NCT02203643.

Structure and signifi cance of cytogenetic abnormalities in patients with multiple myeloma

Introduction. Cytogenetic and genomic traits of tumour cells are considered the key mediating factors in multiple myeloma (MM). Selected chromosomal abnormalities are prognostic of therapeutic response and patient survival in MM.Aim — to assess of the diversity and rate of chromosomal abnormalities in MM patients and their association with the disease course.Materials and methods. The study enrolled 134 MM patients with pre-treatment bone marrow FISH assay screening for chromosomal abnormalities: t(11;14), t(4;14), t(14;16), t(14;20), t(6;14), hyperdiploidy, del13q14/-13, del17p13/TP53, amp1q21, t(8q24)/cMYC. The studied criteria at the MM onset were: hemogram, lactate dehydrogenase (LDH) activity, calcium, β2-microglobulin and creatinine concentrations, punctate cytology, bone marrow trephine biopsy and/or soft tissue biopsy histology, bone X-ray, immunochemical variant of MM, disease staging. A median follow-up was 20 months (3.2–77.4).Results. The primary chromosomal abnormality rate was 82.9 %, among them t(14q32)/IGH — 29.1 %, multiple trisomies — 46.3 % and their combination — 7.5 %. The rates of particular t(14q32)/IGH): t(11;14) — 16.4 %, t(4;14) — 12.7 %, t(14;16) and t(14;20) — 3.7 and 2.2 %, respectively. The secondary chromosomal abnormality rate was 69.4 %, among them del13q14/-13 — 40.3 %, amp1q21 — 39.6 %, t(8q24)/cMYC — 17.2 %, del17p13/TP53 — 12.7 %, del1p32 — 2.2 %. Analyses of the primary–secondary abnormality combinations showed that del13q14/-13 is more frequently combined with t(4;14) and less frequently with trisomies (p &lt; 0.05). Amp1q21 occurs more frequently with t(4;14) and less — with t(11;14) (p&lt;0.05). Patients with t(4;14) more frequently (p &lt; 0.05) had anemia at a hemoglobin level&lt;100 g/L, and the presence of amp1q21 and del17p13/TP53-enhanced serum LDH activity (p &lt; 0.05). Abnormality t(8q24)/cMYC more often co-occurred with higher serum β2-microglobulin concentrations (p &lt; 0.05). A three-year overall survival (OS) in del17p13/TP53-positive patients was 35.5 vs. 71.3 % in the negative (p = 0.002) and 50.8 vs. 67 % — in t(8q24)/cMYC-positive and negative patients, respectively (p = 0.001). Patients without amp1q21, with one, with two or more additional 1q21 copies had a five-year OS 79.4, 67.3 and 20.9 %, respectively (p = 0.0016), and a two-year progression-free survival (PFS) 83, 50 and 0 %, respectively (p = 0.005).Conclusion. We establish a negative impact of del17p13/TP53 and t(8q24)/cMYC on patients’ OS in MM, as well as unfavourable effect of amp1q21 on OS and PFS in the presence of two or more additional copies of 1q21 loci.

V-Domain Ig Suppressor of T Cell Activation (VISTA) Expression Is an Independent Prognostic Factor in Multiple Myeloma.

Simple SummaryMultiple myeloma (MM) is characterized by loss of anti-tumor T-cell immunity. The precise mechanisms by which malignant plasma cells escape T-cell immunity are unknown, although upregulation of checkpoint molecules is seen in progressive disease. The aim of our study was to investigate mechanisms of escape from T-cell immunity. We observed that the expression of V-domain Ig suppressor of T cell activation (VISTA) in the tumor microenvironment is an independent prognostic factor for survival in MM and its major cellular source is tumor infiltrating CD11B+ cells. The combination of high VISTA expression in the tumor combined with low infiltration of CD8+ cells compared to the surrounding stromal tissue is significantly associated with poor survival. These finding have identified VISTA as an interesting target for inhibition to circumvent escape of T-cell immunity.Multiple myeloma (MM) is characterized by loss of anti-tumor T cell immunity. Despite moderate success of treatment with anti-PD1 antibodies, effective treatment is still challenged by poor T cell-mediated control of MM. To better enable identification of shortcomings in T-cell immunity that relate to overall survival (OS), we interrogated transcriptomic data of bone marrow samples from eight clinical trials (n = 1654) and one trial-independent patient cohort (n = 718) for multivariate analysis. Gene expression of V-domain Ig suppressor of T cell activation (VISTA) was observed to correlate to OS [hazard ratio (HR): 0.72; 95% CI: 0.61–0.83; p = 0.005]. Upon imaging the immune contexture of MM bone marrow tissues (n = 22) via multiplex in situ stainings, we demonstrated that VISTA was expressed predominantly by CD11b+ myeloid cells. The combination of abundance of VISTA+, CD11b+ cells in the tumor but not stromal tissue together with low presence of CD8+ T cells in the same tissue compartment, termed a high VISTA-associated T cell exclusion score, was significantly associated with short OS [HR: 16.6; 95% CI: 4.54–62.50; p < 0.0001]. Taken together, the prognostic value of a combined score of VISTA+, CD11b+ and CD8+ cells in the tumor compartment could potentially be utilized to guide stratification of MM patients for immune therapies.

Prognostic factors in multiple myeloma and the impact of the bone involvement

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Multiple myeloma is characterized by abnormal plasmocytes proliferation in the bone marrow, resulting in an immunoglobulin oversecretion, which can cause bone pain, anemia, kidney dysfunction, and infections. The present study evaluates prognostic factors and the bone involvement in patients who had a confirmed diagnosis of MM.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A retrospective study was conducted in hospital universitário São Francisco of Bragança Paulista. Patient demographic data, laboratory parameters and treatment received were recorded. We also analyzed the variables related to diagnosis and the development of bone lesions in MM patients.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; A total of 42 patients had a confirmed diagnosis of MM, out of which most (54.76%) were older than 65. Most patients (45.24%) had beta-2-microglobulin values greater than 5.5 mcg/dl, indicating an advanced stage of the disease and consequently a less favorable prognosis. The main clinical manifestation observed was anemia in 61.90% (26/42) and bone lesions 59.52% (25/42). The analysis of imaging exams showed that most patients presented bone alterations, such as osteopenia, lytic lesions and fractures. Interestingly, 11.90% patients were submitted to autologous bone marrow transplantation with further remission of the disease. Bone marrow transplantation increases overall survival and disease-free survival when compared to conventional treatment.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Since MM prognostic factors are numerous and, therefore, the understanding and analysis of the clinical and laboratory features of MM can contribute to an early diagnosis of patients, a targeted therapeutic approach and better outcomes.&lt;/p&gt;

PHF19 inhibition as a therapeutic target in multiple myeloma

Epigenetic deregulation is increasingly recognized as a contributing pathological factor in multiple myeloma (MM). In particular tri-methylation of H3 lysine 27 (H3K27me3), which is catalyzed by PHD finger protein 19 (PHF19), a subunit of the Polycomb Repressive Complex 2 (PRC2), has recently shown to be a crucial mediator of MM tumorigenicity. Overexpression of PHF19 in MM has been associated with worse clinical outcome. Yet, while there is mounting evidence that PHF19 overexpression plays a crucial role in MM carcinogenesis downstream mechanisms remain to be elucidated. In the current study we use a functional knock down (KD) of PHF19 to investigate the biological role of PHF19 and show that PHF19KD leads to decreased tumor growth in vitro and in vivo. Expression of major cancer players such as bcl2, myc and EGR1 were decreased upon PHF19KD further underscoring the role of PHF19 in MM biology. Additionally, our results highlighted the prognostic impact of PHF19 overexpression, which was significantly associated with worse survival. Overall, our study underscores the premise that targeting the PHF19-PRC2 complex would open up avenues for novel MM therapies.

B-Cell Regeneration Profile and Minimal Residual Disease Status in Bone Marrow of Treated Multiple Myeloma Patients

Simple SummaryB-cell regeneration during therapy has been associated with the outcome of multiple myeloma (MM) patients. However, the effects of therapy and hemodilution in bone marrow (BM) B-cell recovery have not been systematically evaluated. Here, we show that hemodilution is present in a significant fraction of MM BM samples, leading to lower total B-cell, B-cell precursor (BCP), and normal plasma cell (nPC) counts. Among MM BM samples, decreased percentages (vs. healthy donors) of BCP, transitional/naïve B-cell (TBC/NBC) and nPC populations were observed at diagnosis. BM BCP, but not TBC/NBC, increased after induction therapy. At day+100 post-autolo-gous stem cell transplantation, a greater increase in BCP with recovered TBC/NBC numbers but persistently low memory B-cell and nPC counts were found. At the end of therapy, complete response (CR) BM samples showed higher CD19− nPC counts vs. non-CR specimens with no clear association between BM B-cell regeneration profiles and patient outcomes.B-cell regeneration during therapy has been considered as a strong prognostic factor in multiple myeloma (MM). However, the effects of therapy and hemodilution in bone marrow (BM) B-cell recovery have not been systematically evaluated during follow-up. MM (n = 177) and adult (≥50y) healthy donor (HD; n = 14) BM samples were studied by next-generation flow (NGF) to simultaneously assess measurable residual disease (MRD) and residual normal B-cell populations. BM hemodilution was detected in 41 out of 177 (23%) patient samples, leading to lower total B-cell, B-cell precursor (BCP) and normal plasma cell (nPC) counts. Among MM BM, decreased percentages (vs. HD) of BCP, transitional/naïve B-cell (TBC/NBC) and nPC populations were observed at diagnosis. BM BCP increased after induction therapy, whereas TBC/NBC counts remained abnormally low. At day+100 postautologous stem cell transplantation, a greater increase in BCP with recovered TBC/NBC cell numbers but persistently low memory B-cell and nPC counts were found. At the end of therapy, complete response (CR) BM samples showed higher CD19− nPC counts vs. non-CR specimens. MRD positivity was associated with higher BCP and nPC percentages. Hemodilution showed a negative impact on BM B-cell distribution. Different BM B-cell regeneration profiles are present in MM at diagnosis and after therapy with no significant association with patient outcome.

Immunological Prognostic Factors in Multiple Myeloma.

Multiple myeloma (MM) is a plasma cell neoplasm characterized by an abnormal proliferation of clonal, terminally differentiated B lymphocytes. Current approaches for the treatment of MM focus on developing new diagnostic techniques; however, the search for prognostic markers is also crucial. This enables the classification of patients into risk groups and, thus, the selection of the most optimal treatment method. Particular attention should be paid to the possible use of immune factors, as the immune system plays a key role in the formation and course of MM. In this review, we focus on characterizing the components of the immune system that are of prognostic value in MM patients, in order to facilitate the development of new diagnostic and therapeutic directions.

Obesity as a Poor Prognostic Factor in Multiple Myeloma

Aim. To assess the impact of obesity and overweight on the outcomes of multiple myeloma (MM) treatment. Materials &amp; Methods. The present retrospective study enrolled 214 patients with newly diagnosed MM. The median age was 59 years (range 29-89 years), male patients accounted for 40.2 %. The analysis focused on complication incidence, overall survival, and time to the second-line therapy depending on body mass index (BMI) at disease onset. Results. In the groups of patients with BMI &gt; 35 kg/m&lt;sup&gt;2&lt;/sup&gt; and BMI &lt; 35 kg/m&lt;sup&gt;2&lt;/sup&gt; the median overall survival was 42 and 95 months, respectively (hazard ratio [HR] 0.17; 95% confidence interval [95% CI] 0.08-0.37; p &lt; 0.05). In the group of patients with obesity &gt; grade 2 the median time to the second-line therapy was 25 months, being less than in the group of patients with BMI &lt; 35 kg/m&lt;sup&gt;2&lt;/sup&gt; (43 months; HR 0.58; 95% CI 0.31-0.99; p &lt; 0.05). As a result of therapy, the incidence of corticosteroid-associated hyperglycemia and infectious complications as well as the rate of delayed initiation of the next cycle and dose reduction of anticancer drugs were significantly higher in patients with BMI &gt; 35 kg/m&lt;sup&gt;2&lt;/sup&gt; (p &lt; 0.05). Conclusion. Obesity &gt; grade 2 is a poor prognostic factor for complications and is associated with diminishing outcomes of ММ treatment. Accompanying morbid obesity leads to a higher incidence of therapy complications, longer intervals between chemotherapy courses and drug dose reduction.

Real-World Data on Clinical Features, Outcomes, and Prognostic Factors in Multiple Myeloma from Miyazaki Prefecture, Japan.

The prognosis of multiple myeloma (MM) has improved with the introduction of novel agents. These data are largely derived from clinical trials and might not reflect real-world patient outcomes accurately. We surveyed real-world data from 284 patients newly diagnosed with MM between 2010 and 2018 in Miyazaki Prefecture. The median follow-up period was 32.8 months. The median age at diagnosis was 71 years, with 68% of patients aged >65 years. The International Staging System (ISS) stage at diagnosis was I in 18.4% of patients, II in 34.1%, and III in 47.5%. Bortezomib-containing regimens were preferred as initial treatment; they were used in 147 patients (51.8%). In total, 80% of patients were treated with one or more novel agents (thalidomide, lenalidomide, or bortezomib). Among 228 patients who were treated with novel agents as an initial treatment, the overall response rate (partial response (PR) or better) to initial treatment was 78.4%, and the median time to next treatment (TTNT) was 11.6 months. In the multivariate analysis, PR or better responses to initial treatment were independently favorable prognostic factors for TTNT. The median survival time after initial therapy for patients with novel agents was 56.4 months and 3-year overall survival (OS) was 70.4%. In multivariate analysis, ISS stage I/II disease and PR or better response to initial treatment, and autologous stem cell transplantation (ASCT) were identified as independent prognostic factors for overall survival (OS).

Thromboembolism Incidence and Risk Factors in Multiple Myeloma After First Exposure to Immunomodulatory Drug–Based Regimens

BackgroundWe evaluated time to thromboembolism (TE) and risk factors in multiple myeloma (MM) patients after first exposure to immunomodulatory therapy, stratified by thromboprophylaxis. Patients and MethodsWe retrospectively analyzed adult MM patients who received immunomodulatory therapy with or without dexamethasone between February 2012 and October 2017. Thromboprophylaxis included aspirin, anticoagulants (low-molecular-weight heparin, direct oral anticoagulants, or warfarin), or none. Primary endpoint was time to on-treatment TE by thromboprophylaxis type. Time to TE using death as a competing risk censored at 12 months was used in univariate and multivariable analyses to identify risk factors. ResultsOf 485 evaluable patients, 57% were white and 36% African American; median age was 66. Most received lenalidomide (97.5%) and dexamethasone (90%). Half presented with ≥ 1 comorbidities. Sixty-nine had no documented receipt of prophylaxis, 357 aspirin, and 59 anticoagulation. More patients receiving anticoagulants had ≥ 1 comorbidities compared to aspirin or no-prophylaxis groups (P < .001). There was no difference in 12-month estimated cumulative incidence of TE (7.3%; 95% confidence interval, 5.2-9.9) between thromboprophylaxis groups (none 4.4%, aspirin 8.5%, anticoagulant 3.4%) (P = .24). In multivariable analyses, male sex (hazard ratio, 2.50; 95% confidence interval, 1.21-5.17; P = .014) and presence of any comorbidity (hazard ratio, 2.35; 95% confidence interval, 1.17-4.73; P = .016) were associated with TE incidence; thromboprophylaxis type was not (P = .12). ConclusionMale sex and presence of any comorbidity were associated with time to TE. There were no differences in TE incidence between thromboprophylaxis groups despite a higher proportion of those in the anticoagulant group having ≥ 1 comorbidities.