Understanding Of Multiple Myeloma Research Articles

Factors Associated With Survival Among Patients With Multiple Myeloma in Northeastern Tanzania.

This study sought to delineate the clinical, laboratory, and imaging characteristics during multiple myeloma (MM) diagnosis, outline the treatment modalities administered, and ascertain the survival rates among patients with MM over a comprehensive 5-year span in Tanzania. This retrospective cohort study investigated patients diagnosed with MM at the Cancer Care Clinic, Kilimanjaro Christian Medical Centre, between January 2017 and June 2022. Demographic data, clinical profiles, and survival outcomes were collected. The study employed the Kaplan-Meier method to determine overall survival (OS) and survival rates, supported by univariate analysis and a multivariate Cox regression model with significance of P < .05. In this study of 76 patients with MM, bone pain was the most common complaint (76.3%), and patients were age typically older than 50 years (82.5%). Laboratory tests showed frequent abnormalities, such as anemia (51.3%) and hypercalcemia (23.9%). Most patients were at stage III according to Durie Salmon Staging (82.7%), with imaging revealing various bone abnormalities. The median OS was 18.0 months, with 46.1% of patients passing away during the study period. Factors linked to shorter survival included anemia, renal failure, and bone involvement. Infection was the primary cause of death among these patients. The presenting complaint of bone pain significantly affected survival outcomes. This study provides a comprehensive understanding of MM within the Sub-Saharan African context, highlighting age-related disparities in diagnosis, predominant presenting symptoms like bone pain, factors contributing to delayed diagnoses, and the impact on survival rates. The findings underscore the critical need for early recognition, improved diagnostics, and tailored interventions to enhance outcomes for patients with MM in this region.

Unraveling the complexity of drug resistance mechanisms to SINE, T cell-engaging therapies and CELMoDs in multiple myeloma: a comprehensive review.

Despite significant advances in the understanding of multiple myeloma (MM) biology and the development of novel treatment strategies in the last two decades, MM is still an incurable disease. Novel drugs with alternative mechanisms of action, such as selective inhibitors of nuclear export (SINE), modulators of the ubiquitin pathway [cereblon E3 ligase modulatory drugs (CELMoDs)], and T cell redirecting (TCR) therapy, have led to significant improvement in patient outcomes. However, resistance still emerges, posing a major problem for the treatment of myeloma patients. This review summarizes current data on treatment with SINE, TCR therapy, and CELMoDs and explores their mechanism of resistance. Understanding these resistance mechanisms is critical for developing strategies to overcome treatment failure and improve therapeutic outcomes.

Dinaciclib synergizes with BH3 mimetics targeting BCL-2 and BCL-XL in multiple myeloma cell lines partially dependent on MCL-1 and in plasma cells from patients.

A better understanding of multiple myeloma (MM) biology has led to the development of novel therapies. However, MM is still an incurable disease and new pharmacological strategies are needed. Dinaciclib, a multiple cyclin-dependent kinase (CDK) inhibitor, which inhibits CDK1, 2, 5 and 9, displays significant antimyeloma activity as found in phase II clinical trials. In this study, we have explored the mechanism of dinaciclib-induced death and evaluated its enhancement by different BH3 mimetics in MM cell lines as well as in plasma cells from MM patients. Our results indicate a synergistic effect of dinaciclib-based combinations with B-cell lymphoma 2 or B-cell lymphoma extra-large inhibitors, especially in MM cell lines with partial dependence on myeloid cell leukemia sequence 1 (MCL-1). Simultaneous treatment with dinaciclib and BH3 mimetics ABT-199 or A-1155463 additionally showed a synergistic effect in plasma cells from MM patients, ex vivo. Altered MM cytogenetics did not affect dinaciclib response ex vivo, alone or in combined treatment, suggesting that these combinations could be a suitable therapeutic option for patients bearing cytogenetic alterations and poor prognosis. This work also opens the possibility to explore cyclin-dependent kinase 9 inhibition as a targeted therapy in MM patients overexpressing or with high dependence on MCL-1.

Serum NMR-Based Metabolomics Profiling Identifies Lipoprotein Subfraction Variables and Amino Acid Reshuffling in Myeloma Development and Progression.

Multiple myeloma (MM) is an incurable hematological cancer. It is preceded by monoclonal gammopathy of uncertain significance (MGUS)-an asymptomatic phase. It has been demonstrated that early detection increases the 5-year survival rate. However, blood-based biomarkers that enable early disease detection are lacking. Metabolomic and lipoprotein subfraction variable profiling is gaining traction to expand our understanding of disease states and, more specifically, for identifying diagnostic markers in patients with hematological cancers. This study aims to enhance our understanding of multiple myeloma (MM) and identify candidate metabolites, allowing for a more effective preventative treatment. Serum was collected from 25 healthy controls, 20 patients with MGUS, and 30 patients with MM. 1H-NMR (Nuclear Magnetic Resonance) spectroscopy was utilized to evaluate serum samples. The metabolite concentrations were examined using multivariate, univariate, and pathway analysis. Metabolic profiles of the MGUS patients revealed lower levels of alanine, lysine, leucine but higher levels of formic acid when compared to controls. However, metabolic profiling of MM patients, compared to controls, exhibited decreased levels of total Apolipoprotein-A1, HDL-4 Apolipoprotein-A1, HDL-4 Apolipoprotein-A2, HDL Free Cholesterol, HDL-3 Cholesterol and HDL-4 Cholesterol. Lastly, metabolic comparison between MGUS to MM patients primarily indicated alterations in lipoproteins levels: Total Cholesterol, HDL Cholesterol, HDL Free Cholesterol, Total Apolipoprotein-A1, HDL Apolipoprotein-A1, HDL-4 Apolipoprotein-A1 and HDL-4 Phospholipids. This study provides novel insights into the serum metabolic and lipoprotein subfraction changes in patients as they progress from a healthy state to MGUS to MM, which may allow for earlier clinical detection and treatment.

A review of the current status of lenalidomide maintenance therapy in multiple myeloma in 2022

ABSTRACT Introduction Recent advances in the diagnosis and management of multiple myeloma (MM) have improved patient outcomes. This progress in our understanding of MM has resulted in continuous suppressive therapy concepts, including induction, high dose chemotherapy with autologous stem cell transplantation (ASCT), consolidation, and maintenance therapy. The foundation of maintenance therapy has been with lenalidomide. Other novel immunomodulatory drugs (IMiDs), proteasome inhibitors (PIs), and targeted monoclonal antibodies have also contributed to this evolution. Areas covered This review summarizes the outcomes from phase II/III trials with long-term lenalidomide maintenance therapy alone or in combination with other agents in post-ASCT and non-transplant settings for newly diagnosed patients with MM. We review recent data considering a combination with newer medications and ongoing trials. We also review the optimal duration, MRD negativity rate, and safety and tolerability aspects of lenalidomide maintenance therapy. This review aims to present the current and emerging clinical evidence that supports using lenalidomide as a backbone for maintenance therapy in patients with MM. Expert opinion There is increasing evidence to support lenalidomide as the backbone of combination therapy in the maintenance setting.

Relapsed/Refractory Multiple Myeloma in 2020/2021 and Beyond.

Simple SummaryDuring the last two decades, collaborative translational studies utilizing novel methodologies have dramatically advanced our understanding of multiple myeloma (MM) pathophysiology and revolutionized derived treatment strategies. Nevertheless, MM remains an incurable disease, with the vast majority of patients relapsing due to evolving genetic alterations within tumor cell clones as well as the pressure of the immunosuppressive bone marrow (BM) microenvironment. Therefore, continuous translational efforts are needed to further increase our understanding of MM biology, develop rationally derived drugs and to thereby improve patient outcome.Despite the challenges imposed by the COVID-19 pandemic, exciting therapeutic progress continues to be made in MM. New drug approvals for relapsed/refractory (RR)MM in 2020/2021 include the second CD38 monoclonal antibody, isatuximab, the first BCMA-targeting therapy and first-in-class antibody–drug conjugate (ADC) belantamab mafodotin, the first BCMA-targeting CAR T cell product Idecabtagen-Vicleucel (bb2121, Ide-Cel), the first in-class XPO-1 inhibitor selinexor, as well as the first-in-class anti-tumor peptide-drug conjugate, melflufen. The present introductory article of the Special Issue on “Advances in the Treatment of Relapsed and Refractory Multiple Myeloma: Novel Agents, Immunotherapies and Beyond” summarizes the most recent registration trials and emerging immunotherapies in RRMM, gives an overview on latest insights on MM genomics and on tumor-induced changes within the MM microenvironment, and presents some of the most promising rationally derived future therapeutic strategies.

Epidemiology, genetics and treatment of multiple myeloma and precursor diseases.

Multiple myeloma (MM) is a hematological malignancy caused by the clonal expansion of plasma cells. The incidence of MM worldwide is increasing with greater than 140 000 people being diagnosed with MM per year. Whereas 5-year survival after a diagnosis of MM has improved from 28% in 1975 to 56% in 2012, the disease remains essentially incurable. In this review, we summarize our current understanding of MM including its epidemiology, genetics and biology. We will also provide an overview of MM management that has led to improvements in survival, including recent changes to diagnosis and therapies. Areas of unmet need include the management of patients with high-risk MM, those with reduced performance status and those refractory to standard therapies. Ongoing research into the biology and early detection of MM as well as the development of novel therapies, such as immunotherapies, has the potential to influence MM practice in the future.

Brazilian Real-World Multiple Myeloma (MM) Electronic Platform Register Project

Introduction: An epidemiological database is an important tool to characterize the population disease distribution, long-term effects of the diseases, impact of evolving treatments, to identify adverse events (AE) and their possible mitigation and to improve the healthcare system. Another important reason to create a database is to rapidly identify, recruit and enroll individuals for research activities. Based on these, the Brazilian Multiple Myeloma Study Group (GBRAM) developed an electronic database platform with the intention of prospectively registering the MM cases diagnosed at Brazilian healthcare services. Methods: This is a prospective, multicenter, open, epidemiological study, based on an electronic system register. Patients diagnosed with MM after January 1, 2018 have been included. The eligibility criteria were: intent-to-treat (ITT) MM patients, aged over 18 years and under care in any healthcare system (private, public and academic). All clinical and laboratory data, prognostic profiling, treatment patterns and responses, AE and survival were compiled. The data were analyzed with the NCSS® 2020 software. This project is registered in the Brazilian study platform control (Plataforma Brasil) linked to federal health authorities by the number CAAE-05340918.3.1001.8098. Results: To date, 1,113 patients at 44 reference centers were included. The median age was 64 (25 -96) years and 578 (52%) were male. According to the ECOG performance status: 0 = 185 (16.5%), 1 = 257 (23.2%), 2 = 144 (13%), 3 = 105 (9.5%), 4 = 62 (5.5%) and the not available data (NA) = 359 (32.3%). The ISS 1, 2, and 3 were 219 (19.7%), 286 (25.7%) and 406 (36.5%), respectively, the NA being 202 (18.1%). MM isotypes were 524 (47.1%) IgG, 202 (18.2%) IgA, 192 (17.2%) free-light chain, 4 (0.5%) IgM, 7 (0.8%) biclonal, 9 (0.7%) non-secretor and 175 (15.5%) NA. Regarding the treatment backbone, 427 (38.4%) patients received immunomodulators (IMID- thalidomide), 277 (20.4%), proteasome inhibitors (PI-bortezomib), 84 (7.6%), the combination of PI + IMID, 72 (6.6%), combinations with anti-CD38 monoclonal antibody (Daratumumab) and 253 (27%), other treatments. Based on the ITT analysis of 1003 cases, 636 (63.4%) patients were planned for bone marrow transplantation (BMT) and 367 (36.6%) were ineligible. After a median follow-up of 14.0 months, 150 (23.6%) of the planned patients had undergone the procedure, 284 (44.7%) had not yet been submitted and 202 (31.7%) had NA data. The overall survival (OS) was 80.9% for the total group at 20 months, 73.5% for ineligible and 95.5% for eligible. There was a significant improvement in eligible patients who had performed BMT, as compared to those who had not, HR 0.15 (0.09 - 0.26), p &amp;lt; 0.0001. A total of 142 deaths (12.8%) occurred, 51 (36%) of them being during the first 180 days. Discussion: Due to the lack of a reliable national register and the undoubtable need for a better understanding of MM for the development of public health and patient support measures, GBRAM has developed and built an electronic platform. This epidemiological study prospectively enrolled patients diagnosed since January 2018 and is of a nationwide scope. To date, 1,113 new cases were included. Despite the short follow-up, this analysis has identified differences in survival, comparing ISS stratifications and whether a BMT was performed or not. Conclusion: This project demonstrates the feasibility and importance of electronic platforms in the compilation of MM populational data for a better understanding of the clinical characteristics, treatment patterns and outcomes in the real world, permitting a clearer perception of local issues and thus, addressing possible improvement in public healthcare policy, such as the improvement of BMT access. Disclosures De Queiroz Crusoe: Janssen: Research Funding. Aranha:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Ache Pharmaceutics: Honoraria.

The Synchronous Presence of Multiple Myelomas and Other Primary Malignant Tumors: Case Series with Literature Review.

ObjectiveThe synchronous presence of multiple myeloma (MM) and other primary malignant tumors (PMTs) were rarely reported. This study aimed to analyze several cases of MM and other PMTs in order to improve clinicians’ understanding of multiple myeloma (MM) with sMPMTs.MethodsThis study was a retrospective trial. We retrospectively analyzed six cases of the synchronous presence of MM and other PMTs and reviewed the literature to summarize the clinical features and treatment.ResultsThe results showed that five cases of immunoglobulin G (IgG) and one case of kappa light chain; D-S stage: six case of stage III; ISS stage: one case of stage I, two cases of stage II, and three cases of stage III; one case each of gastric cancer (pT2N0MO, stage I), breast cancer (pT1bN0M0, stage I), lung cancer (pT1N0M0, stage I), cervical cancer (stage IB2), thyroid cancer (pT1N0M0, stage I), and diffuse large B-cell lymphoma (Ann-Arbor stage II); three of five patients underwent surgery alone, one patient underwent surgery first and then received chemotherapy at the time of pleural metastasis and the other patient only received radiotherapy; two patients were still alive, three died of progression of MM, and one died of lung cancer. The median survival time was 33.5 months (95% CI, 14.17 to 59.5months).ConclusionThe relationship between synchronous MM and other PMTs remains unknown. Clinicians should improve their understanding of MM with sMPMTs by carrying out multidisciplinary collaboration and a patient-oriented approach to optimize treatment and prolong the survival rates of patients.

Understanding multiple myeloma

Understanding multiple myeloma

Bone Marrow Interaction and Multiple Myeloma - Approximating Reality in Novel High-Throughput Multiple Myeloma Coculture Systems

Introduction: In the past decade, substantial progress has been made in the understanding of multiple myeloma (MM) cell biology and its interaction with the bone marrow microenvironment (BMM). Binding of MM cells to BM stroma cells (BMSCs) alters the expression of SDF-1α and its receptor CXCR4, leading to the secretion of anti-apoptotic cytokines, promoting tumor growth, drug resistance and migration. MM cancer stem cells migrate to endosteal BM niches, where they escape therapies in a quiescent state causing relapse in the course of the disease. The development of novel agents that aim to target the MM and BMM interaction includes drugs as promising as 2nd and 3rdgeneration IMIDs or proteasome inhibitors. Despite these profound advances, the failure rate of preclinically proven cytotoxic single substances is sizeable, as preclinical models often lack the biological, genetic, etiological and immunological properties of the disease (Schüler, Expert. Opin. Biol. Ther. 2013; Kortüm. CLML 2014; Rongvaux. Annu Rev Immunol 2013).Methods & Results: We have previously demonstrated that BM interaction and homing to niches, mediated by the adhesion molecules CXCR4, CD49d and CD44, protect MM cell lines (MMCL) and primary plasma cells (PC) from the cytotoxic effect of anti-MM agents, such as bortezomib (Bor), vorinostat (Vor) and pomalidomide (Pom). Our in vitro and in vivo observed cytotoxic effects from Bor, Vor and Pom confirmed their potent cytotoxicity, whereas cocultivation with M2-10B4 substantially reduced apoptosis and induced tumor protective effects. Additional treatment with the CXCR4 inhibitor AMD3100 blocked CXCR4 in coculture, but left CD49d, CD44 and CD11a widely unchanged. Toxic or therapeutic effects from AMD3100 monotherapy were excluded for the doses used. Comparison of the CXCR4 antibody (ab)-clones 12G5, 44717 and 4G10 revealed that AMD3100 treatment of U266 cells reduced CXCR4 expression with use of 12G5 and 44717, whereas binding of both FITC- and PE-coupled 4G10 was not influenced, making the latter the most reliable for CXCR4 analysis. Use of image cytometry (IC) allowed accurate visualization of co-localisation of CXCR4 expression both on the cell surface and within the cytoplasm of MM cells. IC correlated with flow cytometry-determined CXCR4 expression and allowed the detailed assessment of treatment studies with and without anti-MM agents and AMD3100. Of note, AMD3100 resensitized MM cells to Bor, Vor and Pom (Waldschmidt. Blood 2012:2450), whereas carfilzomib (Cfz) reduced CXCR4 expression in MMCL and could not be antagonized by stroma coculture. Cfz sensitivity was not increased by adding AMD3100 (Simon. Blood 2013:3851). These preclinical studies need additional adaptation to the clinical setting in order to surpass prior drug failure rates, and there is a need to develop more broadly available and better predictive preclinical systems. Therefore, we are currently assessing a 3D co-culture MM model composed of agarose matrix interlayers, based on a novel liquid overlay technique. This model has been specifically adapted to MM cell and BM component interactions as described (Udi. BJH 2013; Zlei. Exp Hematol 2007; Schüler. EOBT 2013). MM cells are cultivated in conical microwells of a non-adherent agarose matrix after BMSCs were plated on the bottom of each plate, allowing the diffusion of soluble cytokines but no direct contact between BMSC and MMCL. Therein, we are presently testing novel anti-MM substances in comparison to our standard-coculture system.Conclusion: Targeting microenvironmental mediators, like SDF-1α and CXCR4, is a promising approach to expand the choice of antimyeloma agents and amplify the effects of established antimyeloma drugs, as previously shown by us and others for the combination of AMD3100 and Bor or Pom. However, as our knowledge on MM and its BMM has dramatically increased a great effort has been made in the preclinical testing of promising new anti-MM agents, and more complex high-throughput in vitro models are urgently needed to better predict the potency of these substances in order to reduce dropouts in clinical trials. We hereby provide a novel approach which better reflects the spatial growth of human MM samples in BMSC coculture, and more closely mimics the growth and proliferation of human MM clones in vivo. DisclosuresNo relevant conflicts of interest to declare.

Biology and treatment of myeloma.

In recent years significant progress has been made in the understanding of multiple myeloma (MM) biology and its treatment. Current strategies for the treatment of MM involve the concept of sequential blocks of therapy given as an induction followed by consolidation and maintenance. In an age characterized by emerging and more powerful laboratory techniques, it is of primary importance to understand the biology of MM and how this biology can guide the development of new treatment strategies. This review focuses on the genetic basis of myeloma, including the most common genetic abnormalities and pathways affected and the effects that these have on MM treatment strategies. MM biology is discussed also in the light of more recent theory of intraclonal heterogeneity.

Leveraging The Old With The New: Exploring and Integrating Historic Microarray Studies With Next Generation Sequencing For Multiple Myeloma

Remarkable advances in our ability to study the molecular profiles of human cancers by Next Generation Sequencing (NGS) methods are in rapid progress. The promise of scientific discovery that is offered by NGS also includes the challenge concerning the interpretation of large and non-trivial experimental results. This task is potentially further complicated when a multitude of molecular profiling modalities are available, with the goal of a more integrative type analysis of the cancer biology.As technology advances, it is critical to leverage what has been gained from historic approaches (e.g., microarrays) to new approaches (NGS). Microarray transcriptome analyses have resulted in important advances in biomedicine. For instance in multiple myeloma (MM), microarray approaches led to the development of a prognostic 70 gene risk score as well as an effective disease subtyping via cluster assignment. Both enabled an improved molecular understanding of MM, and have provided translational information for the purposes of more advanced patient management. Many researchers are now transitioning to NGS DNA approaches for the detection of sequence variants, as well as RNA-seq, also due to its discovery-based nature, improved sensitivity, and dynamic range. Additionally, RNA-seq allows for the analysis of gene isoforms, splice variants, novel gene fusions, etc. There is now a pressing need to associate and integrate microarray and NGS data via advanced bioinformatic approaches.Utilizing a model-view-controller (MVC) approach, a suite of custom software tools have been developed to integrate NGS experimental data along with microarray and Affymetix probe set-IDs, and gene annotation information from a variety of public sources, e.g., Affy HG-U133 Plus 2 release 33, Ensembl gene annotations and cross references for GRCh37, and NCBI gene annotations. The approach employs a variety of strategies to integrate, annotate, and associate microarray and NGS datasets. Output from the Tuxedo suite and GATK can be directly integrated, and/or associated with microarray and Affymetrix probe set data, as well as necessary gene identifiers and/or symbols from a variety of sources. Strategies are employed to maximize the integration and annotation processes across molecular profiling modalities. To further enhance a cancer biology focus, novel gene sets (e.g., MM 70 risk score) can be specified. Finally, the tool can be directly interfaced into a NGS pipeline. As a proof of concept, a custom MM gene list composed of CCND1, CCND3, DKK1, FGFR3, MAF, MAFB, NFKB, and WHSC1 were applied to NGS data sets derived from the MM cell lines RMPI-8226 and H929, which were obtained from ATCC. All NGS experiments were run on an Illumina HiSeq-2000 using 101 bp PE sequencing. Agilent SureSelect was used for whole exome sample prep and Illumina TrueSeq mRNA kit v2 with poly-A selection for RNA-seq. Integrative visualizations and renderings of MM molecular biology will be illustrated.A novel bioinformatic approach to aid in the facilitation of both annotation and association of historic microarray data in conjunction with richer NGS data is now assisting with the study of MM cancer biology. Disclosures:No relevant conflicts of interest to declare.

Towards the integration, annotation and association of historical microarray experiments with RNA-seq

BackgroundTranscriptome analysis by microarrays has produced important advances in biomedicine. For instance in multiple myeloma (MM), microarray approaches led to the development of an effective disease subtyping via cluster assignment, and a 70 gene risk score. Both enabled an improved molecular understanding of MM, and have provided prognostic information for the purposes of clinical management. Many researchers are now transitioning to Next Generation Sequencing (NGS) approaches and RNA-seq in particular, due to its discovery-based nature, improved sensitivity, and dynamic range. Additionally, RNA-seq allows for the analysis of gene isoforms, splice variants, and novel gene fusions. Given the voluminous amounts of historical microarray data, there is now a need to associate and integrate microarray and RNA-seq data via advanced bioinformatic approaches.MethodsCustom software was developed following a model-view-controller (MVC) approach to integrate Affymetrix probe set-IDs, and gene annotation information from a variety of sources. The tool/approach employs an assortment of strategies to integrate, cross reference, and associate microarray and RNA-seq datasets.ResultsOutput from a variety of transcriptome reconstruction and quantitation tools (e.g., Cufflinks) can be directly integrated, and/or associated with Affymetrix probe set data, as well as necessary gene identifiers and/or symbols from a diversity of sources. Strategies are employed to maximize the annotation and cross referencing process. Custom gene sets (e.g., MM 70 risk score (GEP-70)) can be specified, and the tool can be directly assimilated into an RNA-seq pipeline.ConclusionA novel bioinformatic approach to aid in the facilitation of both annotation and association of historic microarray data, in conjunction with richer RNA-seq data, is now assisting with the study of MM cancer biology.

Novel Targeted Therapies and Combinations for the Treatment of Multiple Myeloma

Multiple myeloma is a B-cell neoplasm that is characterized by clonal proliferation of terminally differentiated plasma cells. Approximately 20,000 new cases are diagnosed each year with a prevalence of about 60,000. Characteristic clinical features include bone disease, hypercalcemia, renal disease, anemia and infections. Advancements in our understanding of multiple myeloma have led to a significant impact in the natural history of the disease. Despite these advances the disease remains incurable and most patients invariably relapse and die. Our understanding of the transformation of normal plasma cells into myeloma cells and the interaction between myeloma cells and elements of the bone marrow microenvironment that sustain proliferation and survival has significantly improved. This knowledge has paved the way for the development of novel drugs that target the genetic and molecular changes that underlie myeloma pathophysiology. In this review we discuss several of these novel agents. We focus on the specific pathways targeted by these drugs and the role they may play in development or progression of multiple myeloma. We also discuss the proposed mechanism of action of these drugs and correlate these to clinical trials where they have been investigated.

Proteomic analysis of multiple myeloma: Current status and future perspectives

Multiple myeloma (MM) is a malignant plasma cell neoplasm that accounts for slightly more than 10% of all hematologic cancers and remains incurable. The major challenge remains the identification of better diagnosis and prognostic biomarkers. The advent of proteomic technologies creates new opportunities and challenges for those seeking to gain greater understanding of MM. Although there is a limited number of proteomic studies to date in MM, those performed highlight the potential impact of these technologies in our understanding of MM pathogenesis and the identification of novel therapeutic targets. In this review, we introduce the proteomic technologies available for the study of MM, summarize results of the published proteomic studies on MM, and discuss the novel developments and applications for the analysis of protein PTM in MM. The application of proteomic technologies will be valuable to better understand the pathogenesis of MM and may in the future open novel avenues in the treatment of MM.

Engraftment Capacity of Intratibialy Injected Multiple Myeloma Patient-Derived Bone Marrow-Cells In Vivo

AbstractAbstract 3010 Introduction:In order to allow a better understanding of multiple myeloma (MM), the establishment of functional and reproducible in vivo models is widely pursued. Of available model systems, xenografts in immunodeficient mice reproduce the clinical situation advantageously. Here, the engraftment capacity of MM patient-derived bone marrow cells implanted into NOD/SCID-IL2-receptor-gamma-chain-/- (NSG) mice was meticulously investigated. Material and Methods:Bone marrow cells from 7 MM patients were injected intratibialy into NSG mice (n=5/patient). As controls, 5 mice received healthy donor bone marrow and 5 mice were mock-injected. Tumor growth was monitored via a) daily MM-symptom acquisition, such as hind limb paresis, apathy and consistent foot dragging, b) FACS (human HLA-A,B,C; CD138; CD45; CD38) and c) fluorescence-based in vivo imaging (FI, Kodak FX, Alexa750 labeled anti-human CD138, CD38, CD45 and HLA-ABC) in bone marrow, peripheral blood, spleen and lymph node sites of the respective animals. Results:There were significant differences in engraftment capacity, persistence of human cells and expression of selected markers between bone marrow of MM patients and healthy donors: 1.) infiltration of the spleen and lymph nodes was exclusively detected in NSG-mice bearing patient-derived MM cells, whereas cells of healthy donors were - if detected - exclusively found within the murine bone marrow; 2.) mean FI-areas in the bone marrow of MM-patient-derived injected mice were significantly increased as compared to mice bearing bone marrow cells of healthy donors (p=0.006); 3.) patient-derived MM cells expressed CD138, CD38 and HLA-ABC. In contrast, bone marrow cells of healthy donors expressed exclusively CD45 and CD138. The CD138 cell population determined by FACS in patients' bone marrow cells (before NSG-injection) decreased from a median of 11.3% to 0.8% 56 days after implantation (in NSG mice), either due to preferably CD138-negative plasma cell engraftment or the CD138 loss within the murine environment as previously described.Fifty-six days after implantation, patient-derived MM cells could be detected in all animals via FACS-analysis. Follow-up analyses by FI confirmed, that bone marrow engraftment was prominent and observed in all (35/35) NSG mice, albeit also in others organs. Patient-derived MM cells within the bone marrow could be detected in parallel via FACS- and FI-analyses in 10 NSG mice and within the peripheral blood in 12 NSG mice (total of 35 mice being examined). Maximal bone marrow-, peripheral blood- and spleen-engraftment numbers in NSG mice were as high as 4%, 25% and 52%, respectively, suggesting that in peripheral blood- and spleen-sites, MM-cell engraftment could even surmount that of bone marrow-sites. Spleen and other organ involvement observed in our xenografts have been confirmed in previous murine MM-models (Murillo et al. Clin Cancer Res, 2008), postulating that similarly to spleen-colony-forming-cells in hematopoiesis, spleen and other sites serve as fertile tumor engraftment locations.Differences in engraftment capacity and expression pattern between respective patient-derived MM specimen were evident, but did not strikingly correlate with MM-patients' characteristics, such as MM-subtypes, disease stage or expression pattern of the primary material; this observation also well correlating with previous reports (e.g. (Pilarski et al. Blood, 2000). Conclusions:Murine MM-models have shown to be exceedingly challenging in their ability to induce valid and trustworthy MM-patient-derived cell engraftment; here our NSG model suggest to harbor MM-cells. Our data demonstrates that intratibially-injected NSG mice mimic the clinical MM disease with respect to the disseminated nature of the disease and the indispensable engraftment of clonogenic plasma cells into the bone marrow. Collection of whole-body FI data proved to be a time- and animal-saving analysis that allows to closely monitor MM growth. Disclosures:No relevant conflicts of interest to declare.

The Combination of Vorinostat and Bortezomib Provides Long-Term Responses in Patients with Relapsed or Refractory Multiple Myeloma.

Abstract 3886Poster Board III-822 IntroductionA better understanding of multiple myeloma (MM) disease biology has led to the development of targeted agents such as the proteasome inhibitor bortezomib. While bortezomib has provided significant survival advantages for both previously untreated and treated patients with MM, nearly all patients eventually relapse or become refractory to bortezomib therapy. Therefore, there remains a need to develop specific new approaches that are active against MM or enhance the efficacy of existing treatments. Vorinostat (Zolinza®), a potent oral inhibitor of Class I and Class II histone deacetylase (HDAC) enzymes, has demonstrated antiproliferative and proapoptotic activity in preclinical models of MM as a single agent and in combination with bortezomib. Preliminary results from an ongoing open-label, escalating dose, multicenter Phase I trial of vorinostat in combination with bortezomib have shown that the combination is generally well tolerated and effective in heavily pretreated patients with advanced MM (Weber et al. Clinical Lymphoma and Myeloma 2009; 9: S44, abstract A248), including patients refractory to prior bortezomib treatment (Weber et al. Clinical Lymphoma and Myeloma 2009; 9: S42, abstract A242). Here we report the safety and efficacy results for a cohort of patients with relapsed/refractory MM who have received ≥12 cycles of treatment with vorinostat in combination with bortezomib. MethodsPatients (aged ≥18 years) with relapsed or refractory MM (ECOG performance status 0-2) were sequentially enrolled on escalating doses of vorinostat combination therapy using a standard 3+3 design for ≤8 cycles. Cycles were repeated every 21 days and consisted of vorinostat 200 mg bid or 400 mg once daily (Days 1-14) in combination with bortezomib 0.7 or 0.9 mg/m2 i.v. on Days 4, 8, 11, and 15; or escalated to 0.9, 1.1, or 1.3 mg/m2 i.v. on Days 1, 4, 8, and 11. The addition of oral dexamethasone 20 mg on Days 1-4 and 9-12 of each cycle was permitted for disease progression (PD). Patients without disease progression at Cycle 8 were allowed to continue on study treatment. ResultsOf the 34 patients who have entered the study, 9 have received combined vorinostat and bortezomib treatment for ≥12 cycles and are the focus of this report. In this population, drug-related adverse events (AEs) occurred in 9/9 patients; 99% of these AEs were mild to moderate in severity (NCI Grade 1-3) and 6 patients had serious AEs (9 events). One patient experienced Grade 4 neutropenia, and 5 patients experienced Grade 3 drug-related AEs. The most common drug-related toxicities of any grade were diarrhea, nausea, and fatigue. The best responses observed in 9 evaluable patients were 5 partial response (duration 147 to 609 days), 2 minimal response (duration 42 to 161 days), and 2 stable disease (duration 371 to 742 days). Seven of 9 patients have now discontinued treatment; all due to progressive disease (median [range] time to progression was 294 days [42 to 742 days]). ConclusionsThese preliminary data indicate that extended treatment with vorinostat in combination with bortezomib (+/- dexamethasone) administered in a 21-day cycle shows significant long-term clinical activity with acceptable tolerability in patients with relapsed/refractory MM. Disclosures:Jagannath:Celgene: Honoraria; Millennium: Ad Board, Honoraria; Merck: Honoraria. Off Label Use: Vorinostat is a histone deacetylase (HDAC) inhibitor that was approved in the FDA in October 2006 for the treatment of cutaneous manifestations in patients with cutaneous T-cell lymphoma (CTCL) who have progressive, persistent, or recurrent disease on or following two systemic therapies. Weber:Millenium: Research Funding, Speakers Bureau; Celgene : Research Funding, Speakers Bureau; Merck : Research Funding, unpaid advisory board. Schiller:Denzyme: Research Funding; Cellegne: Research Funding; Eli Lilly: Research Funding; Centocor: Research Funding; Millennium: Research Funding, Speakers Bureau; Novartis: Research Funding, Speakers Bureau; Merck: Consultancy, Research Funding; Vion: Research Funding. Lupinacci:Merck: Employment, Equity Ownership. Reiser:Merck: Employment, Equity Ownership. Allen:Merck: Employment, Equity Ownership. Rizvi:Merck: Employment, Equity Ownership.

Interim Analyses of the MMRC Reference Collection Identifies Recurrent Genomic-Level Events in Multiple Myeloma and Demonstrates That CDKN2C/p18 Deletion Is the Pre-Eminent Copy Number Alteration in Poor Prognosis Disease

The Multiple Myeloma Research Consortium (MMRC) Genomics Initiative was instigated to harness the power of multiple genomic approaches to further the understanding of multiple myeloma. To date, 137 samples from patients with newly diagnosed and relapsed myeloma (out of an estimated final total of 250 by the end of the year) have been subjected to expression profiling and array comparative genomic hybridization. To identify regions of recurrent copy number alteration with a high degree of confidence, we have used the Genomic Identification of Significant Targets In Cancer (GISTIC) algorithm, which detects such regions and assigns a probability to each. Application of GISTIC to the MMRC collection identified 14 significant regions of amplification and 15 significant regions of deletion. The algorithm further detects peaks of copy number change that contribute to each region's significance. Of genes that were expressed in our dataset, a total of 64 across the genome were found to lie within the boundaries of significant amplification peaks and 30 were found to lie within significant deletion peaks. Given the likelihood that this gene collection is highly enriched for genes important in the pathogenesis of myeloma and potential therapeutic targets, it has been prioritized for further validation with the amplified genes submitted for arrayed RNAi and the deleted genes expedited for re-sequencing. In order to define a poor prognosis group, we developed and applied a model based on the gene expression dataset of Shaughnessy and colleagues. To identify pathways activated in poor prognosis disease, we applied Gene Set Enrichment Analysis with the Molecular Signatures Database. This demonstrated enrichment of multiple canonical pathways within the poor prognosis group, including those associated with proliferation, cell cycle progression and DNA repair. A search for recurrent copy number events associated with poor prognosis disease revealed that by far the most significant event, and the only one surviving correction for multiple hypothesis testing, was mono- or bi-allelic deletion of CDKN2C (p18). Interestingly, the poor prognosis group also demonstrated higher expression of p18 in those samples without bi-allelic deletion and of CDKN2A (p16). Deletion and increased expression of p18 in high proliferation index myeloma samples has previously been described. However, our analyses demonstrate the pre-eminence of p18 loss for defining poor prognosis disease compared to other recurrent copy number changes. Furthermore, it expands on work in other tumors demonstrating feedback mechanisms between cyclin dependent kinase inhibitor pathways, suggesting a more complex model of interplay between the pathways than previously described. In conclusion, the MMRC reference collection is proving an important tool in the fight to understand key genetic events in multiple myeloma and would ultimately be anticipated to contribute towards development of improved therapy for the disease.

Individualizing Treatment of Patients With Myeloma in the Era of Novel Agents

Progress in the understanding of multiple myeloma (MM) cell biology has led to the identification of new relevant prognostic factors and subsequently different risk groups. This concept, together with the recent discovery of new drugs with novel mechanisms of action, will probably lead to individualized treatment according to the different patients' characteristics. In this review, we focus on current available agents already approved for MM, and discuss individualized treatment approaches for both transplantation candidates (subdivided into standard and high-risk patients) and elderly patients. Future progress in MM will be based on using science to inform the design of the optimal combined treatments, and high throughput assays that can assess the ability of combination therapies to induce death of MM cells, both alone and in the bone marrow microenvironment.