1q Gain Research Articles

Prognostic value of t(4;14) translocation in newly diagnosed multiple myeloma patients in novel agent era

ABSTRACTObjectiveTo evaluate the prognostic value of t(4; 14) translocation for newly diagnosed multiple myeloma (MM) patients in the novel agent era.MethodsWe retrospectively analyzed 606 newly diagnosed MM patients treated with novel agents. The propensity score matching technique was used to reduce the bias between groups.ResultsAmong 606 patients, t(4; 14) was observed in 108 (17.8%) patients, among which 79 (73.1%) were accompanied by 1q21 gain and/or del 17p. Median overall survival (OS) (56.2 vs. 87.3 months) and progression-free survival (PFS) (25.7 vs. 37.6 months) were significantly shorter in patients with t(4;14) compared with patients without cytogenetic abnormalities. Univariate Cox proportional hazards regression analysis showed that the t(4;14) was not associated with shorter OS (p = 0.666) and PFS (p = 0.164). The multivariable analysis also showed t(4;14) was not a poor prognostic factor for OS and PFS of patients with newly diagnosed MM (p > 0.05). After balancing the distribution of factors between patients with and without t(4;14) by the propensity score matching technique, patients with t(4;14) had similar OS (57.6 vs. 56.5 months, p = 0.964) and PFS (26.5 vs. 28.1 months, p = 0.740) with the patients without t(4;14).ConclusionsThese results demonstrated that t(4; 14) alone may be not a poor prognostic factor patients with newly diagnosed MM in the novel agent era.

Identification of recurrent 3q13.31 chromosomal rearrangement indicates LSAMP as a tumor suppressor gene in neuroblastoma.

Neuroblastoma (NB) is a childhood malignancy of the sympathetic nervous system. NB is mainly driven by copy number alterations, such as MYCN amplification, large deletions of chromosome arm 11q and gain of chromosome arm 17q, which are all markers of high‑risk disease. Genes targeted by recurrent, smaller, focal alterations include CDKN2A/B, TERT, PTPRD and ATRX. Our previous study on relapsed NB detected recurrent structural alterations centered at limbic system‑associated membrane protein (LSAMP; HUGO Gene Nomenclature Committee: 6705; chromosomal location 3q13.31), which is a gene frequently reported to be deleted or downregulated in other types of cancer. Notably, in cancer, LSAMP has been shown to have tumor‑suppressing functions. The present study performed an expanded investigation using whole genome sequencing of tumors from 35 patients, mainly with high‑risk NB. Focal duplications or deletions targeting LSAMP were detected in six cases (17%), whereas single nucleotide polymorphism‑microarray analysis of 16 NB cell lines detected segmental alterations at 3q13.31 in seven out of the 16 NB cell lines (44%). Furthermore, low expression of LSAMP in NB tumors was significantly associated with poor overall and event‑free survival. Invitro, knockdown of LSAMP in NB cell lines increased cell proliferation, whereas overexpression decreased proliferation and viability. These findings supported a tumor suppressor role for LSAMP in NB. However, the higher incidence of LSAMP aberrations in cell lines and in relapsed NB tumors suggested that these alterations were a late event predominantly in advanced NB with a poor prognosis, indicating a role of LSAMP in tumor progression rather than in tumor initiation. In conclusion, the present study demonstrated recurrent genomic aberrations of chromosomal region 3q13.31 that targeted the LSAMP gene, which encodes a membrane protein involved in cell adhesion, central nervous system development and neurite outgrowth. The frequent aberrations affecting LSAMP, together with functional evidence, suggested an anti‑proliferative role of LSAMP in NB.

A novel human multiple myeloma cell line with a 1q21 gain genetic abnormality and CKS1B overexpression.

Multiple myeloma (MM) is an incurable hematologic malignancy mainly due to its cytogenetic abnormalities. Therefore, it is important to establish permanent malignant MM cell lines as tools to develop more effective therapies. Pleural effusion cells of a 70-year-old patient was collected to establish the CZ2 cell line. Characterization of CZ2 was determined with nephelometry, flow cytometry, fluorescence in situ hybridization (FISH), and chromosomal microarray analysis (CMA). Western blotting analysis was adopted to determine protein expression. Cell viability was measured by the 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay. We established and characterized a new MM cell line, CZ2. Using nephelometry and flow cytometry, cells with typical plasma cell morphology but not classical plasma cell phenotype were found to be non-immunoglobulin-secretary cells. FISH analysis of cells revealed a unique characteristic, namely, that there was only gain of the 1q21 region (1q21+). No other common cytogenetic abnormalities in MM, such as deletion of 17p (17p-), deletion of 13q (13q-), or translocation of immunoglobulin heavy chain (IgH), were observed. In addition, the original cell line maintains its single cytogenetic abnormality. Meanwhile, we observed through western blotting that CDC28 protein kinase regulatory subunit 1B (CKS1B), an adverse prognostic gene located in the 1q21 region, was highly expressed in CZ2. Knockdown of CKS1B reduced cell viability and also increased the levels of cleaved-poly(ADP-ribose) polymerase (cleaved-PARP) and cleaved-caspase3. CZ2 provides a suitable material for cellular and molecular studies of MM with only a 1q21 abnormality. This cell line is characterized by a gain of 1q21, and the high expression of CKS1B is an important model for studies of myeloma cell growth and drug resistance during therapy.

Impact of autologous stem cell transplantation (ASCT) on progression free survival (PFS) in newly diagnosed multiple myeloma patients (NDMM) with high risk cytogenetic abnormalities.

ASCT has been considered the standard of care for younger patients with NDMM, however, not all the studies published so far have uniformly demonstrated the complete superiority of ASCT over chemotherapy at standard doses. A systematic review and meta-analysis of randomized studies has shown a significant benefit with single ASCT in terms of prolonged progression-free survival (PFS), but not of overall survival (OS). In our retrospective analysis we investigated the impact of high dose (HD) chemotherapy followed by ASCT in special population of patients with high risk cytogenetic profile on the PFS and treatment outcome. Retrospective analysis of NDMM patients eligible for HD chemotherapy followed by upfront ASCT in the era of novel agents, who underwent the ASCT in the Department of hematology and oncohematology LF UPJŠ and UNLP Košice in the timeframe of 54 months (from 01/JAN/2019 to 30/JUN/2023). Patients were stratified according to their cytogenetic profile. PFS was defined by the time from ASCT to the disease progression. The OS was defined as the time from the the start of treatment to the death from disease progression. The high risk cytogenetic abnormalities (HRCA) were defined as t(4;14), del(17/17p), t(14;16), t(14;20), nonhyperploidy, gain (1q). Inclusion criteria were met by 65 patients with NDMM who received HD chemotherpy followed by ASCT. We identified 22 (33.8 %) patients with HRCA and 43 (66.2 %) patients with standard cytogenetic risk. During the monitored period we recorded 4 deaths due to disease progression, all of them in the HCRA subgroup. The response was enhanced by the ASCT in both subgroups. The very good partial response (VGPR) increased from 42 % to 46 % and complete remission (CR) increased from 23 % to 45 % after the ASCT. The number of patients achieving only partial response (PR) decreased from 35 % to 9 % after ASCT. In the subgroup of patients with HRCA the median PFS after ASCT was lower compared to the patients with standard cytogenetic risk (17 vs 38 months). The average PFS in both subgroups was 22.9 months. The median OS in both subgroups was not reached, however the only deaths due to disease progression were recorded in the HRCA subgroup. At the time of analysis, 100 % (43) of patients are alive in the standard cytogenetic subgroup versus 72 % (18) of patients in HRCA subgroup. HD chemotherapy followed by ASCT remains the standard of care for NDMM eligible for high dose chemotherapy. Our results confirm the benefit of ASCT even in the presence of HRCA. Lower PFS in the HRCA subgroup might indicate the need for more intensive treatment, which may be achieved by tandem ASCT defined as two ASCT performed within a period of no more than six months. Additionally, as three- and four-drug induction therapies are becoming increasingly available and effective, resulting in high minimal residual disease (MRD) negative rates, it is important to continue discussing and further personalizing upfront ASCT to avoid overtreatment and possible toxicities especially in the non-high-risk patient population (Tab. 5, Fig. 2, Ref. 9).

Dissecting molecular mechanisms of immune microenvironment dysfunction in multiple myeloma and precursor conditions.

Multiple myeloma (MM) is a disease of clonally differentiated plasma cells. MM is almost always preceded by precursor conditions, monoclonal gammopathy of unknown significance (MGUS), and smoldering MM (SMM) through largely unknown molecular events. Genetic alterations of the malignant plasma cells play a critical role in patient clinical outcomes. Del(17p), t(4;14), and additional chromosomal alterations such as del(1p32), gain(1q) and MYC translocations are involved in active MM evolution. Interestingly, these genetic alterations appear strikingly similar in transformed plasma cell (PC) clones from MGUS, SMM, and MM stages. Recent studies show that effectors of the innate and adaptive immune response show marked dysfunction and skewing towards a tolerant environment that favors disease progression. The MM myeloid compartment is characterized by myeloid-derived suppressor cells (MDSCs), dendritic cells as well as M2-like phenotype macrophages that promote immune evasion. Major deregulations are found in the lymphoid compartment as well, with skewing towards immune tolerant Th17 and Treg and inhibition of CD8+ cytotoxic and CD4+ activated effector T cells. In summary, this review will provide an overview of the complex cross-talk between MM plasma cells and immune cells in the microenvironment and the molecular mechanisms promoting progression from precursor states to full-blown myeloma.

The Token Transition-Minimal Deviation AdenocarcinomaUterine Cervix

Gastric type adenocarcinoma is a high grade, frequently discerned mucinous adenocarcinoma with gastric differentiation incriminating the endocervical canal. Of obscure aetiology, neoplasm depicts STK11 genetic mutations with chromosome 3q gain and chromosome 1p loss. Tumefaction exhibits cytological and histological features of gastric differentiation as tumour cells incorporated with voluminous, clear or pale, foamy, eosinophilic cytoplasm, tall, abundant, apical mucin, miniature, spherical, elliptical or enlarged, basal nuclei, irregular, vesicular chromatin and prominent nucleoli. The well differentiated neoplasm is comprised of well defined glandular articulations and minimal to absent stromal desmoplastic reaction. Neoplastic glands of variable outline, magnitude and irregular or claw-like glandular contour are observed. Tumour cells appear immune reactive to HIK1083, MUC6, p53, carcinoembryonic antigen (CEA) or mCEA, CK7, PAX8, CAIX or HNF-1B. Minimal deviation adenocarcinoma requires segregation from neoplasms such as human papillomavirus (HPV) associated endocervical adenocarcinoma, human papillomavirus (HPV) associated endocervical adenocarcinomas intestinal(goblet cell) type, clear cell adenocarcinoma, invasive stratified mucin producing adenocarcinoma, metastatic gastric or pancreaticobiliary carcinoma, lobular endocervical glandular hyperplasia, atypical lobular endocervical glandular hyperplasia, diffuse laminar endocervical glandular hyperplasia, tunnel clusters, florid deep glands, microglandular hyperplasia, pseudo-infiltrative tubal metaplasia, endocervicosis, endosalpingosis or endocervical type adenomyoma. Minimal deviation adenocarcinoma can be adequately categorized upon histological examination of tissue obtained with surgical sampling. Stage I tumours may be managed with surgical procedures as trachelectomy or radical hysterectomy and regional lymphadenectomy upon initial disease representation

Optimizing the value of lenalidomide maintenance by extended genetic profiling: an analysis of 556 patients in the Myeloma XI trial

AbstractPrediction of individual patient benefit from lenalidomide (Len) maintenance after autologous stem cell transplant (ASCT) remains challenging. Here, we investigated extended molecular profiling for outcome prediction in patients in the National Cancer Research Institute Myeloma XI (MyXI) trial. Patients in the MyXI trial randomized to Len maintenance or observation after ASCT were genetically profiled for t(4;14), t(14;16), t(14;20), del(1p), gain(1q), and del(17p) and co-occurrence of risk markers was computed. Progression-free survival (PFS), subsequent progression (PFS2), and overall survival (OS) were calculated from maintenance randomization, and groups were compared using Cox proportional hazards regression. Of 556 patients, 17% with double-hit multiple myeloma (MM) (≥2 risk markers), 32% with single-hit (1 risk marker), and 51% without risk markers were analyzed. Single-hit MM derived the highest PFS benefit from Len maintenance, specifically, isolated del(1p), del(17p), and t(4;14), with ∼40-fold, 10-fold, and sevenfold reduced risk of progression or death (PFS), respectively, compared with observation. This benefit translated into improved PFS2 and OS for this group of patients compared with observation; median PFS was 10.9 vs 57.3 months for observation vs Len maintenance. Patients with isolated gain(1q) derived no benefit, and double-hit MM limited benefit (regardless or risk lesions involved) from Len maintenance. Extended genetic profiling identifies patients deriving exceptional benefit from Len maintenance and should be considered for newly diagnosed patients to support management discussions along their treatment pathway. This trial was registered at www.isrctn.com/ISRCTN49407852 as # ISRCTN49407852.

Targeted deep sequencing reveals genomic alterations of actinic keratosis/cutaneous squamous cell carcinoma in situ and cutaneous squamous cell carcinoma.

Actinic keratosis (AK) and cutaneous squamous cell carcinoma in situ (CIS) are two of the most common precursors of cutaneous squamous cell carcinoma (cSCC). However, the genomic landscape of AK/CIS and the drivers of cSCC progression remain to be elucidated. The aim of our study was to investigate the genomic alterations between AK/CIS and cSCC in terms of somatic mutations and copy number alterations (CNAs). We performed targeted deep sequencing of 160 cancer-related genes with a median coverage of 515× for AK (N=9), CIS (N=9), cSCC lesions (N=13), and matched germline controls from 17 patients. cSCC harboured higher abundance of total mutations, driver mutations and CNAs than AK/CIS. Driver mutations were found in TP53 (81%), NOTCH1 (32%), RB1 (26%) and CDKN2A (19%). All AK/CIS and cSCC lesions (93.5%), except two, harboured TP53 or NOTCH1 mutations, some of which were known oncogenic mutations or reported mutations in normal skin. RB1 driver mutations were found in CIS/cSCC (36.4%) but not in AK. CDKN2A driver mutations were found more frequently in cSCC (30.8%) than in AK/CIS (11.1%). Among recurrent (≥3 samples) CNAs (gain in MYC and PIK3CA/SOX2/TP63; loss in CDKN2A and RB1), MYC (8q) gain and CDKN2A (9p) loss were more frequently detected in cSCC (30.8%) than in AK/CIS (11.1%). Ultraviolet was responsible for the majority of somatic mutations in both AK/CIS and cSCC. Our study revealed that AK/CIS lesions harbour prevalent TP53 or NOTCH1 mutations and that additional somatic mutations and CNAs may lead to cSCC progression in AK/CIS lesions.

The adverse impact of a gain in chromosome 1q on the prognosis of multiple myeloma treated with bortezomib-based regimens: A retrospective single-center study in China.

Multiple myeloma is genetically heterogeneous, and chromosome abnormalities play a pivotal role in prognosis. A gain in chromosome 1q (+1q) is among the most common cytogenetic abnormalities; however, its relationship with overall survival (OS) and progression-free survival (PFS) in patients with multiple myeloma is still unclear. We aim to clarify the impact of +1q on the clinical characteristics and survival outcomes of patients treated with bortezomib-based combination regimes. We retrospectively analyzed 258 patients first diagnosed with myeloma who underwent bortezomib-based therapy at the bone marrow transplantation department of a multiple myeloma treatment center in the first affiliated hospital of Zhejiang University, China. We identified 258 newly diagnosed patients with multiple myeloma in our department from July 2013 to September 2018. We observed that 127 (49.2%) of the patients acquired +1q at diagnosis, and +1q strongly correlated with the occurrence of del(13q) and IgH rearrangement (P < 0.001). In the patients with +1q, the PFS was 22.2 months (95% CI 15.8-28.5 months), and the three-year and five-year PFS was 35.1% and 15.3%, respectively. Univariate analysis revealed that albumin, lactate dehydrogenase (LDH), and the percentage of plasma cells significantly affected PFS. Multivariate analysis showed that LDH and the percentage of plasma cells significantly affected PFS in the +1q patients. In terms of OS, the median OS for the +1q patients was 47.4 months (95% CI 34.7-59.5), while the OS of the non-+1q patients was not reached (P = 0.048). The univariate and multivariate analyses revealed that age, platelet count, and extramedullary lesions were significant adverse factors for OS in the +1q patients. There were no statistical differences between PFS and OS when there were other chromosomal abnormalities, but there was a decreased tendency in PFS. LDH and +1q also had a synergistic adverse effect on survival. +1q is associated with a higher tumor burden and correlated with the occurrence of del(13q) and IgH rearrangement at diagnosis. In the era of novel agents, +1q still significantly affects PFS and OS.

Carfilzomib induction, consolidation, and maintenance with or without autologous stem-cell transplantation in patients with newly diagnosed multiple myeloma: pre-planned cytogenetic subgroup analysis of the randomised, phase 2 FORTE trial

Carfilzomib induction, consolidation, and maintenance with or without autologous stem-cell transplantation in patients with newly diagnosed multiple myeloma: pre-planned cytogenetic subgroup analysis of the randomised, phase 2 FORTE trial

Harmonica consensus, controversies, and future directions in radiotherapy for pediatric Wilms tumors.

Radiotherapy (RT) is essential for multimodality treatment of pediatric renal tumors, particularly in higher-risk and metastatic disease. Despite decades of use, particularly for Wilms tumor, there remain controversies regarding RT indications, timing, dose, and targets. To align global management, we address these issues in this international HARMONIsation and CollAboration (HARMONICA) project. There are multiple knowledge gaps and opportunities for future research including: (1) utilization of advanced RT technologies, including intensity-modulated RT, proton beam therapy, combined with image-guided RT to reduce target volumes; (2) impact of molecular biomarkers including loss of heterozygosity at 1p, 16q, and 1q gain on RT indications; (3) mitigation of reproductive toxicity following RT; (4) promotion of RT late effects research; and (5) support to overcome challenges in RT utilization in low- and middle-income countries where 90% of the world's children reside. Here, we outline current status and future directions for RT in pediatric renal tumors.

Evidence for etiologic field changes in tongue distant from tumor in patients with squamous cell carcinoma of the oral tongue.

Oral cancer is a paradigm of Slaughter's concept of field cancerization, where tumors are thought to originate within an area of cells containing genetic alterations that predispose to cancer development. The field size is unclear but may represent a large area of tissue, and the origin of mutations is also unclear. Here, we analyzed whole exome and transcriptome features in contralateral tumor-distal tongue (i.e. distant from the tumor, not tumor-adjacent) and corresponding tumor tissues of 15 patients with squamous cell carcinoma of the oral tongue. The number of point mutations ranged from 41 to 237 in tumors and from one to 78 in tumor-distal samples. Tumor-distal samples showed mainly clock-like (associated with aging) or tobacco smoking mutational signatures. Tumors additionally showed mutations that associate with cytidine deaminase AID/APOBEC enzyme activities or a UV-like signature. Importantly, no point mutations were shared between a tumor and the matched tumor-distal sample in any patient. TP53 was the most frequently mutated gene in tumors (67%), whereas a TP53 mutation was detected in only one tumor-distal sample, and this mutation was not shared with the matched tumor. Arm-level copy number variation (CNV) was found in 12 tumors, with loss of chromosome (Chr) 8p or gain of 8q being the most frequent events. Two tumor-distal samples showed a gain of Chr8, which was associated with increased expression of Chr8-located genes in these samples, although gene ontology did not show a role for these genes in oncogenic processes. In situ hybridization revealed a mixed pattern of Chr8 gain and neutral copy number in both tumor cells and adjacent nontumor epithelium in one patient. We conclude that distant field cancerization exists but does not present as tumor-related mutational events. The data are compatible with etiologic field effects, rather than classical monoclonal field cancerization theory. © 2022 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

Systems biology network reveals the correlation between COX-2 expression and Ch 7q copy number alterations in Ch 11q-deleted pediatric neuroblastoma tumors.

Tumor-associated inflammation and chromosomal aberrations can play crucial roles in cancer development and progression. In neuroblastoma (NB), the enzyme cyclooxygenase-2 (COX-2) is associated with copy number alterations on the long arm of chromosome 11 (Ch 11q), defining an aggressive disease subset. This retrospective study included formalin-fixed paraffin-embedded tumor samples collected from nine patients during diagnosis at the pediatric Pequeno Principe Hospital, Curitiba, PR, Brazil, and post-chemotherapy (CT). COX-2 expression was evaluated using immunohistochemistry and correlated with the genome profile of paired pre- and post-CT samples, determined by array comparative genomic hybridization. A systems biology approach elucidated the PTGS2 network interaction. The results showed positive correlations between pre-CT Ch 7q gain and COX-2 expression (ρ = 0.825; p-value = 0.006) and negative correlations between Ch 7q gain and Ch 11q deletion (ρ = -0.919; p-value = 0.0005). Three samples showed Ch 11q deletion and Ch 7q gain. Network analysis identified a direct connection between CAV-1 (Ch 7q) and COX-2 in NB tumors and highlighted the connection between amplified genes in Ch 7q and deleted ones in 11q. The identification of hub-bottleneck-switch genes provides new biological insights into this connection between NB, tumorigenesis, and inflammation.

Recurrent posterior fossa group A (PFA) ependymoma in a young child with constitutional mismatch repair deficiency (CMMRD).

Recurrent posterior fossa group A (PFA) ependymoma in a young child with constitutional mismatch repair deficiency (CMMRD).

Biallelic deletion of 1p32 defines ultra-high-risk myeloma, but monoallelic del(1p32) remains a strong prognostic factor

AbstractCytogenetic abnormalities (CAs) are known to be the preponderant prognostic factor in multiple myeloma. Our team has recently developed a prognostic score based on 6 CAs, with which del(1p32) appears to be the second worst abnormality after del(17p). This study aimed to confirm the adverse effect of 1p32 deletion in patients with newly diagnosed multiple myeloma (NDMM). Among 2551 patients with newly diagnosed multiple myeloma, 11% were harboring del(1p32). Their overall survival (OS) was significantly inferior compared with patients without del(1p32) (median OS: 49 months vs 124 months). Likewise, progression-free survival was significantly shorter. More importantly, biallelic del(1p32) conferred a dramatically poorer prognosis than a monoallelic del(1p32) (median OS: 25 months vs 60 months). As expected, the OS of patients with del(1p32) significantly decreased when this abnormality was associated with other high-risk CAs [del(17p), t(4;14), or gain(1q)]. In the multivariate analysis, del(1p32) appeared as a negative prognostic factor; after adjustment for age and treatment, the risk of progression was 1.3 times higher among patients harboring del(1p32), and the risk of death was 1.9 times higher. At the dawn of risk-adapted treatment strategies, we have confirmed the adverse effect of del(1p32) in multiple myeloma and the relevance of its assessment at diagnosis.

Long-Term Outcomes of Autologous Hematopoietic Cell Transplant of Multiple Myeloma: A 10 Year Follow up Study

Introduction: Multiple myeloma (MM) is a disorder of plasma cell proliferation that affects 1 in 132 humans in the United States. While the disease is generally characterized by good initial response rates, the majority of MM patients eventually relapse. Autologous Hematopoietic Cell Transplantation (AHCT) is the current standard of care for patients who demonstrate response to initial therapy; however, long-term studies looking at the association between certain demographic, clinical and cytogenetic factors with long-term outcomes post-AHCT are scarce. We report herein our AHCT outcomes over the past 10 years. Methods: We retrospectively reviewed the electronic medical records of all MM patients who underwent AHCT at Cleveland Clinic between January 1st, 2011 and January 15th 2021. Demographic characteristics, time to transplant, cytogenetic risk, International Scoring System (ISS), labs, lines of treatment, response (per International Myeloma Working Group criteria), overall survival and progression free survival were collected through chart review. Cox proportional hazards regression analysis using the Statistical Package for Social Sciences (SPSS) was performed to determine factors that significantly and independently affect relapse and overall survival. Kaplan-Meier analysis was performed to compare the median overall survival (mOS) and median progression free survival (mPFS) according to the cytogenetic risk. Results: A total of 517 patients with median follow up of 32.9 months were included, of whom FISH cytogenetics and ISS were available in 413 and 424, respectively. Our cohort had a median age at AHCT of 60.2 years and male preponderance of 58.2%. ECOG performance status was 0 in 158 (30.6%), 1 in 321 (62.2%), 2 in 36 (7%) and 3 in 1 (0.2%) at AHCT. Of patients with available ISS, 160 (37.7%) had stage I, 165 (38.9%) had stage II and 99 (23.3%) had stage III. Standard risk (SR) and high risk (HR) FISH were present in 279 (67.6%) and 134 (32.4%) patients, respectively, and the most common abnormalities were del (13q) (33.9%) followed by t(11;14) (22.0%), gain 1q (18.2%), del(17p) (10.7%) and t(4;14) (7.7%). Most patients had IgG (68.9%) followed by IgA (23.5%) MM. Median lines of treatment pre-AHCT was 1 (range 1-9), while 132 (25.5%) had complete response (CR), 176 (34%) had very good partial response (VGPR), and 209 (40.4%) had partial response (PR) pre-AHCT. Looking into factors affecting outcomes, our analysis suggested that HR cytogenetics (HR 2.34, 1.34-4.03 95% CI, P=0.003) and treatment lines of ≥2 pre-AHCT (HR 1.35, 1.03-1.7 95% CI, P=0.024) were independent risk factors for lower OS. In contrast, age at AHCT (HR 1.04, 0.98-1.04 95% CI), male sex (HR 1.05, 0.63-1.73 95% CI), white ethnicity (vs African American HR 1.23, 0.49-3.08 95% CI; vs Other ethnicities HR 1.19, 0.16-9.00 95% CI), time to transplant of ≥12 months (HR 1.35, 0.77-2.39 95% CI), ISS stage III (vs stage I HR 0.94, 0.49-1.82 95% CI; vs stage II HR 1.29, 0.69-2.39 95% CI), and PR disease status pre-ASCT (vs VGPR HR 1.26, 0.71-2.2 95% CI; vs CR HR 1.46, 0.68-3.12 95% CI) did not significantly influence OS. On the other hand, HR cytogenetics (HR 3.12, 2.09-4.66 95% CI, P<0.0001), smoking history (vs never smokers HR 1.51, 1.12-2.04 95% CI, P=0.006) and PR disease status pre-AHCT (vs CR HR 2.11, 1.25-3.56, P=0.005; vs VGPR HR 1.19, 0.81-1.74 95% CI) were found to be independent risk factors for earlier relapse, as opposed to the rest of the factors similarly analyzed for OS. We then focused our Cox model on determining specific HR cytogenetic features that independently affect either OS or PFS. Our results suggested that t(14;16) (HR 3.93, 1.94-7.97 95% CI, P<0.0001), followed by del(17p) (HR 2.75, 1.51-5.00 95% CI, P=0.001) and t(4;14) (HR 2.10, 1.17-3.77 95% CI, P=0.013) independently lower OS. Similarly t(14;16) (HR 5.05, 2.83-8.99 95% CI, P<0.0001), del(17p) (HR 3.49, 2.23-5.44 95% CI, P<0.0001), t(4;14) (HR 2.46, 1.56-3.88 95% CI, P<0.0001) as well as gain (1q) (HR 2.32, 1.54-3.51 95% CI, P=0.009) independently lower PFS. Kaplan Meier-based survival analysis further confirmed a lower mOS (67.4 months vs unreached, P<0.0001) (Fig 1A) and mPFS (21.9 vs 64.2 months, P<0.0001) (Fig 1B) for HR vs SR cytogenetics. Conclusion: OS post-AHCT in MM patients is mainly affected by HR cytogenetics and number of treatment lines pre-AHCT. HR cytogenetics affects PFS as well, which is also influenced by a smoking history and the pre-AHCT disease status. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Gain of chr1q Portends Poor Outcomes in Multiple Myeloma Patients Treated with Venetoclax

Venetoclax is a BH3-mimetic small molecule that selectively inhibits the anti-apoptotic protein BCL-2 and triggers cell death. While it is only approved for Acute Myeloid Leukemia (AML) and Chronic Lymphocytic Leukemia (CLL), its use in Multiple Myeloma (MM) in clinical trials has demonstrated excellent activity as a single agent and in combination with other therapies, particularly in patients carrying the t(11;14) translocation involving CCND1 (Kumar et al, Lancet Oncol 2020; Ehsan et al, J Hematol 2021). In this study, we sought to investigate the genomic determinants of response to venetoclax in a real-world setting outside of clinical trials. In an IRB-approved retrospective review of the Mount Sinai Electronic Medical Record, we identified 58 MM patients who received Venetoclax between 2017 and 2022. Most of these patients received Venetoclax in combination with other therapeutics, including the monoclonal antibody Daratumumab, proteasome inhibitors (PI), immune-modulatory drugs (IMID) and the HDAC inhibitor Panobinostat, and only 5 received Venetoclax as single agent. Patients had received a median of 4 previous lines of therapy (range 1-18). The median progression-free survival (PFS) was 7.13 months, with an ORR of 53% (defined as PR or better). Most patients exhibited the t(11;14) translocation of CCND1 (n=48, 83%), which was likely used as a biomarker for patient selection, given its association with better response to the drug as suggested by previous literature. Median PFS in t(11;14) patients was 7.41 months vs 4 months in patients in the non-t(11;14) group (p=0.07). Further stratification based on gain of 1q revealed that patients with t(11;14) and concurrent gain of 1q (n=19; 39.5%) had significantly worse PFS than patients with t(11;14) alone (HR=5.4; 95% CI: 1.9-15.1; p<0.001) (Fig. 1A). These findings were confirmed also in multivariate analysis including potential confounding variables such as age, sex, race, previous lines of therapy, and ISS. While t(11;14) was associated with a more durable response, we observed cases of fast progression in the t(11;14) group, as well as cases with durable response in the non-t(11;14) group, indicating that other markers should be investigated for better identification of patients who are more likely to benefit from this treatment. RNA-seq data was available for 46 of the 58 patients, which we analyzed to determine potential gene expression markers of response. First, we evaluated markers proposed in previous studies, such as BCL2, MCL1 and the BCL2/BCL2L1 and BCL2/MCL1 ratios, stratifying patients based on median PFS. Our analysis showed a trend towards higher expression of BCL2 (p=0.07) and the BCL2/MCL1 ratio (p=0.07), as well as significant up-regulation of the BCL2/BCL2L1 ratio in patients with higher PFS (p<0.05). No significant difference was observed in the expression of MCL1. To further determine potential novel markers of response, we performed elastic-net regularized regression to predict PFS, which identified a predictive signature of 6 genes (ATP1B3, MYL2, CNR1, FKBPL, LRRK2-DT, LINC02541). The Kaplan-Meier estimator showed significant stratification of patients according to the signature, where up-regulation corresponded to significantly shorter PFS compared with medium expression and down-regulation (p<0.0001) (Fig. 1B). Furthermore, the signature was significantly associated with depth of response, where up-regulation identified non-responders (less than PR; n=22) vs responders (PR and above; n=23) (p<0.05). To validate the predictive power of this signature, we analyzed a dataset with 20 RNA-seq samples from patients who received Venetoclax monotherapy from a recent independent study (Gupta et al., Blood 2021). Since PFS data was not available, we evaluated the signature using Best Response to stratify patients in responders (PR and above; n=10) and non-responders (less than PR; n=10). Concordantly with the results obtained on our dataset, up-regulation of the signature significantly identified non-responders (p=0.01). In conclusion, here we report that gain of 1q is associated with shorter response to venetoclax in MM, including patients with t(11;14), and the identification of a novel six-gene signature that predicts response to the drug in terms of both duration and depth of response. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Structural Heterogeneity of Chromosome 1q Drives Outcome in Newly Diagnoses Myeloma

Background: The prognostic importance of 1q gain, present in 30% of cases, has led to it being extensively studied and incorporated into prognostic systems. Amplification (>3 copies) of 1q is seen in 10% of cases and has a greater degree of specificity for poor outcome than gain alone. Despite this, there is ongoing debate about its value, likely due to differences in the nature and penetrance of deregulated drivers. To gain insight into this we dissected the structural changes seen at the 1q level and integrated them with expression and clinical data to identify potential drivers and gain insight into progression mechanisms. Methods We analyzed data derived from 1,154 CoMMpass trial patients including 972 NDMM patients with whole exome for mutations, and 752 whole genomes for copy number (CNA), translocations, and complex rearrangements. Using GISTIC 2.0 and PFC we identified hotspots of CNA. This information was analyzed in conjunction with the RNA-seq data derived from 643 patients to determine the aberrant transcriptional landscape of 1q. Results: We identified nine regions of gain (numbered G1 to G9), eight of them being on 1q. Several potential oncogenes such as BCL9 (G2), MCL1 (G3), SLAMF7 (G5), POU2F1 (G6), and BTG2 (G8) lay within these regions of gain. Of note, other previously identified drivers lay outside specific hotspots: ANP32E (306 kb downstream of G3) CKS1B and ADAR1 (1209 kb ( and 1561 kb away from G4, respectively), ATF6 (941 kb from G5), and PBX1 (2313 kb upstream of G6). These data suggest that although important, these hotpots do not drive the entire spectrum of genes upregulated as a consequence of gain 1q. We noted that 302 samples (40%) had at least one gained region with 80% (241/302) having gain of 7-9 regions; 69% (207/302) had gain G2-G9. Each of the gained regions occurred at a similar frequency (G2-G9 range 79-87%) with the exception of G1 located at the sub-telomeric border of 1p seen only in 6% (18/302) of patients. There were 219 cases with gain of G2-G9. These results show two broad groups of gain 1q; whole arm gains and a group with focal gain. Patients with whole arm gain had a worse PFS (HR 1.3 (95% CI 1.01-1.6) and OS (HR 1.6 (95% CI 1.15-2.2) than patients with no 1q gain; the outcome for patients focal events was neutral. Whole arm gains strongly associated with a complex genomic background including with t(4;14) (corr=0.10, BF=1.06), loss of acrocentric chromosomes (del(13q) corr=0.23, BF=118623 and del(14q) corr=0.12, BF=2.9) and other deletions (del(4p) corr=0.11, BF=1.89, del(16p) corr=0.12, BF=2.3) and negatively correlated to trisomies and t(11;14) (corr=0.16, BF=184). Interestingly whole arm gains had significantly shorter telomeres and a higher mean age, and patients with critically short tumor telomeres were over-represented (Corr=0.11, BF=1.2). Common associations with CKS1B gain are mostly found in the whole arm gains group. Amp(1q) was over represented in the whole arm gain group (87%) and associated with the worst outcome (data not shown). Similarly, focal events strongly associated with templated insertion (corr=0.34, BF=6e14), MYC translocation (corr=0.24, BF=3034538), and HRD (corr=0.13, BF=4.9). To address expression changes in focal changes we compared patients with no 1q gain (n=297) with patients with a focal event (n=56); we identified 20 genes of which the majority (n=12) were located on chromosome 1 and related to protein handling. We compared patients with no evidence of 1q gain with patients with a whole arm gain (n= 157); the number of deregulated genes was higher both on 1q and overall (n=585 and n=2409 respectively) suggesting that generalized gene deregulation is part of a more complex genome wide mechanism. Interestingly, 101 were transcription factors and included upregulation of BACH2, NR5A1, MYBL1. GLMP, and E2F2 and downregulation of PAX5, SMAD1, TBX21, SIX4, EGR3, and GF1 most of them being involved in histone methylation, intracellular signaling, and regulation of transcription. Conclusions: Our data add precision by which 1q is associated with an adverse outcome and an aggressive disease phenotype by separating out focal gains, that occur on a favorable background and associate with a good outcome and those with arm-length gains, associated with high-risk disease features, deregulation of multiple transcriptional programs, increased metabolism and aggressive clinical behavior. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Young Adults with Multiple Myeloma Have Distinct Clinical and Molecular Characteristics Compared to Older Patients

Introduction Multiple Myeloma (MM) is an incurable plasma cell malignancy with a median age of 65 years at diagnosis. Although previous studies in "young” MM have been performed, they focus on the clinical characteristics. Within this study, we aim to understand the clinical characteristics and genomic drivers of young MM using the Weill Cornell/New York Presbyterian (WCM) and CoMMpass (MMRF) registry. Methods Young MM was defined as onset of MM at age <= 45. The WCM MM registry was queried for patient meeting the diagnosis for MM based on International Myeloma Working Group (IMWG). A control population of MM was created by randomly sampling the patients within the registry that were >45 years old. Clinical features and outcomes were recorded for each patient. The MMRF study is an observational international registry of newly diagnosed MM. A total of 1143 patients had clinical data. Baseline demographic, clinical and laboratory data, along with treatment and genomic (whole exome sequencing, RNA sequencing) was collected, and patients were followed prospectively every 6 months. Patients were divided into <= 45-year group and those above the median age in this cohort (>63 year). The primary end point of our analysis was progression free survival (PFS). Kaplan Meier and univariable Cox proportional hazard model was performed. Multivariable Cox model was created based on the results of univariable model. Land-mark analysis was used to control for time-dependent covariates. All analysis was performed using R software, version 4.1 Results The WCM cohort consisted of a total of 179 patients for this study. 61 patients were <= 45 years, and 98 patients belonging to an older control group. The younger-patients group was enriched for individuals of African American descent (40% vs 10%, p = 0.04), stage I ISS (51% vs 34%, p 0.01), more use of autologous stem cell transplant (ASCT), and less frequent prior diagnosis of smoldering myeloma (SM) (2.3% vs 18%, p = 0.017). There was a trend of higher rates of EMD and higher free light chain ratio in the young group, but this was not statistically significant. The median PFS for each group was 7.92 years (95% CI 4.50 - NA) for the younger group and 3.25 years (95% CI 1.92 - 10.67) for the >45-year group. In the univariable model the >45 year had worse PFS (HR 2.4, 95CI 1.2-4.6, p < 0.01). The association of worse PFS in the >45 year group (HR 6.3, 95%CI 2.3-17.2) persisted in the multivariable analysis, in addition to the presence of EMD (HR 3.2, 95% CI 1.4-7.3), and ISS stage (Table 2). In the MMRF registry, 65 and 548 patients <= 45 years and >63 years respectively were identified. The young group had higher proportion of African American (33% vs 15%, p 0.01), lower ISS (stage I 46% vs 31%, p = 0.04), and less frequency of deletion 13q (35% vs 50%, p 0.03) and gain 1q (22% vs 42%, p < 0.01). t(4;14) was seen more frequently in the young group, but this was not statistically significant (18% vs 9%, p = 0.056). DEA and GSEA showed a total of 1945 (3.5%) and 2164 (3.9%) over and under expressed genes, with the young group being enriched for the CD-1 transcriptional signatures (NES 1.86, adjusted p 0.028). There were no differences in the rates of mutation in the top 23 mutated genes in MM. The median PFS for the young group was 5.0 years (95% CI 2.3 - 5.9) vs 5.4 (95% CI 5.4 - 5.8) years, HR 1.56 (95% CI 1.05-2.3, p = 0.02) on the univariable analysis. Conclusions Young patients with MM have distinct clinical and demographic characteristics, including higher rates in African Americans, lower ISS stage, and lower rates of deletion 13q and gain 1q and enrichment in the CD-1 MM signature suggesting a potential role genetic and environmental factors in the early presentation at diagnosis. However, young patients had comparable to improved PFS than older patients that could be attributed to both biologic drivers, or factors related to patient age, such as better performance status, aggressive treatment, and potentially better tolerance leading to more exposure to antimyeloma therapy. The impact of EMD and ISS have been well described in MM, and the presence of EMD in this population remains an important prognostic factor. Lastly, although we used an arbitrary cut-off of 45 years old, we acknowledge this population may well represent biological spectrum of disease subtypes with potential differences in disease kinetics. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Co-Occurrence of High-Risk Lesions Is a Consistent Predictor of Ultra-High Risk Multiple Myeloma in Newly Diagnosed and Relapsed/Refractory Patients - Meta-Analysis of 5,808 Trial Patients

Background: Myeloma patient outcomes remain heterogeneous, despite improving treatment options for newly diagnosed (NDMM) and relapsed/refractory (RRMM) disease. Improved individual risk prediction is highly desirable to support physicians and patients in increasingly complex joint decision-making processes. There is a specific need for readily accessible and easy to implement risk prediction tools that allow application in clinical trials and standard care. We previously reported on the utility of extended genetic profiling for refined outcome prediction in NDMM, including gain(1q), t(4;14) and del(17p) as a minimum set, to enable calling co-occurrence of two or more risk lesions, also termed double hit. To investigate its utility for prognostication in a wider context, we performed a meta-analysis of randomized clinical trials including in total 11150 patients with extended molecular profiling data for 5808 NDMM and RRMM patients. Methods: This collaboration of the EMN, UNITO, HOVON, UK-MRA and GMMG academic study groups, to which industry contributed results following request, identified in total 14 prospective randomized interventional trials with availability of extended genetic profiles, i.e. complete information on risk markers gain(1q), t(4;14), del(17p) as minimum requirement, which were included in the analysis: nine trials for NDMM (four including transplant eligible (TE), three transplant ineligible (TNE), two both) and five trials for RRMM. Outcome analysis in relation to presence of no (no hit), one (single hit) or two or more (double hit) risk markers was performed for each trial individually using Cox proportional hazards models. Summary level meta-analysis was performed using the generic inverse-variance method in a random-effects model to synthesize hazard ratios (HR) for progression-free survival (PFS) and overall survival (OS). Heterogeneity was assessed using the I2 statistic and Cochran's Q test. Results: In total 5808 trial patients were included in the analysis, 4807 NDMM patients (3296 transplant-eligible (TE), 1511 transplant-ineligible (TNE)), as well as 1001 patients with RRMM. Frequencies for presence of single (median: 38%; range 32%-48%) or double hit (14%; 9%-22%) were comparable between trials. OS was shortest for patients with double hit disease; meta-analysis summary HR for OS were 2.97 (95% CI: 2.37-3.71; P<0.0001) for double hit and 1.87 (95% CI: 1.60-2.19; P<0.0001) for single hit by meta-analysis (Figure 1). Summary HRs for PFS by meta-analysis were 2.18 (95% CI: 1.92-2.47; P<0.0001) for double hit and 1.63 (1.43-1.86; P<0.0001) for single hit. Estimated between-study heterogeneity was moderate (I2: 25%-59%). Results were consistent between NDMM and RRMM trials, and between trials with proteasome inhibitor (e.g. GMMG-HD4/HOVON-65; MUKFive) and immunomodulatory drug (IMiD) based regimens (e.g. GMMG-MM5; MUKSeven)(Figure 1). The association of double hit with shortened OS was most pronounced for trials with modern, intensive PI/IMiD induction/ASCT/maintenance treatments concepts, including FORTE (OS HR: 8.22; 95% CI: 4.06-16.65), GMMG-HD6 (OS HR 4.21; 2.20-8.08) and NCRI Myeloma XI (TE; OS HR: 3.65; 2.75-4.83). Hazard ratios were lower in trials for older, transplant-ineligible patients, but outcome was still consistently poorest for those patients with double hit MM. Conclusions: This large meta-analysis demonstrates consistent risk-discrimination by extended genetic profiling in NDMM and, for the first time, RRMM. Our results strongly support assessment of and reporting on single hit/high risk and double hit/ultra-high risk patient groups in clinical trials, including trials for RRMM. These data also highlight the importance of access to extended genetic profiling in routine patient care, with the minimum requirement of obtaining a complete set of results for gain(1q), t(4;14) and del(17p) for all patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal