Epstein-Barr virus-positive multiple myeloma developing after immunosuppressant therapy for rheumatoid arthritis: a case report and review of literature

A 61-year-old woman was diagnosed as having rheumatoid arthritis (RA) and began treatment with salazosulfapyridine (SASP) and methotrexate (MTX) in 2008; the administration of concomitant tacrolimus (TAC) was initiated in 2010. She subsequently developed concurrent multiple myeloma (MM), immunoglobulin G (IgG)-κ type, in 2012. A portion of the tumor cells tested positive for Epstein-Barr virus-encoded small RNA (EBER). MTX treatment was discontinued in 2014, and the exacerbation of MM ensued. The patient received two cycles of bortezomib plus dexamethasone (BD) therapy and attained a complete response (CR). She then underwent an autologous peripheral blood stem cell transplantation. The Epstein-Barr (EB) virus infection arising from the increased RA disease activity and immunosuppressant medication might have influenced the development of MM in this case. Most reported patients with EB virus-positive plasmacytoma are in a state of immunosuppression, and this condition may fall within the category of other iatrogenic immunodeficiency-associated lymphoproliferative disorders. No other reports of plasmacytoma occurring in a background of RA or after TAC or MTX therapy have been made, and the present case is the first such report.

[The epidemiology of multiple myeloma]

We investigated epidemiology of multiple myeloma (MM), referring to recent papers. This article includes three points: 1) the progression rate of monoclonal gammopathy of undetermined significance (MGUS) to MM, 2) the effect of radiation to prevalence of MM, and 3) secondary malignancy after chemotherapy used to treat MM. The risk of progression from MGUS to MM is 1% per year. The researches of atomic bomb showed that there is no increase of risk of MM after radiation exposure. In contrast, studies investigating workers in nuclear power plants point out that radiation exposure over 50 mSv increases risk of MM. The incidence of secondary malignancy after chemotherapy used to treat MM was about 5%. This article will help to review recent researches about epidemiology of MM.

[The pathology of smoldering multiple myeloma]

The precursor states (named as monoclonal gammopathy of undetermined significance [MGUS] and smoldering multiple myeloma [SMM]) consistently exist before symptomatic multiple myeloma is diagnosed. After approximately 30 years have passed since Kyle et al. advocated MGUS and SMM for the first time, the pathology and prognosis of these diseases have been clarified considerably. Recently, the safety and efficacy of the early treatment for the patients with high risk SMM are shown. In this article, the current understanding of the pathology of SMM as well as MGUS including the diagnosis, prognosis and treatment is reviewed.

[Diagnostic criteria of multiple myeloma]

Multiple myeloma is a disease showing heterogeneous symptoms and varieties of laboratory findings. Although there have been many efforts trying to diagnose this disease in a simple way, no simple criteria was available until International Myeloma Working Group (IMWG) criteria has proposed. In this review, detailed IMWG criteria for diagnosis of multiple myeloma are described.

Understanding biology to tackle the disease: Multiple myeloma from bench to bedside, and back

Multiple myeloma (MM) is a cancer of antibody-producing plasma cells. The pathognomonic laboratory finding is a monoclonal immunoglobulin or free light chain in the serum and/or urine in association with bone marrow infiltration by malignant plasma cells. MM develops from a premalignant condition, monoclonal gammopathy of undetermined significance (MGUS), often via an intermediate stage termed smoldering multiple myeloma (SMM), which differs from active myeloma by the absence of disease-related end-organ damage. Unlike MGUS and SMM, active MM requires therapy. Over the past 6 decades, major advancements in the care of MM patients have occurred, in particular, the introduction of novel agents (ie, proteasome inhibitors, immunomodulatory agents) and the implementation of hematopoietic stem cell transplantation in suitable candidates. The effectiveness and good tolerability of novel agents allowed for their combined use in induction, consolidation, and maintenance therapy, resulting in deeper and more sustained clinical response and extended progression-free and overall survival. Previously a rapidly lethal cancer with few therapeutic options, MM is the hematologic cancer with the most novel US Food and Drug Administration-approved drugs in the past 15 years. These advances have resulted in more frequent long-term remissions, transforming MM into a chronic illness for many patients.

CXCR7-dependent angiogenic mononuclear cell trafficking regulates tumor progression in multiple myeloma

The CXCR4/stromal cell-derived factor-1 (SDF-1) axis is essential for cell trafficking and has been shown to regulate tumor progression and metastasis in many tumors including multiple myeloma (MM). A second chemokine receptor for SDF-1, CXCR7 was discovered recently and found on activated endothelial cells. We examined the role of CXCR7 in angiogenic mononuclear cells (AMCs) trafficking in MM. Our data demonstrate that AMCs are circulating in patients with MM and in vivo studies show that they specifically home to areas of MM tumor growth. CXCR7 expression is important for regulating trafficking and homing of AMCs into areas of MM tumor growth and neoangiogenesis. We demonstrate that the CXCR7 inhibitor, POL6926, abrogated trafficking of AMCs to areas of MM tumor progression leading to a significant inhibition of tumor progression. These effects were through regulation of endothelial cells and not through a direct tumor effect, indicating that targeting a bone marrow microenvironmental cell can lead to a delay in MM tumor progression. In conclusion, our studies demonstrate that CXCR7 may play an important role in the regulation of tumor progression in MM through an indirect effect on the recruitment of AMCs to areas of MM tumor growth in the bone marrow niche.

Cancer incidence among firefighters: 45 years of follow-up in five Nordic countries

OBJECTIVES

Firefighters are potentially exposed to a wide range of known and suspected carcinogens through their work. The objectives of this study were to examine the patterns of cancer among Nordic firefighters, and to compare them with the results from previous studies.

METHODS

Data for this study were drawn from a linkage between the census data for 15 million people from the five Nordic countries and their cancer registries for the period 1961-2005. SIR analyses were conducted with the cancer incidence rates for the entire national study populations used as reference rates.

RESULTS

A total of 16 422 male firefighters were included in the final cohort. A moderate excess risk was seen for all cancer sites combined, (SIR=1.06, 95% CI 1.02 to 1.11). There were statistically significant excesses in the age category of 30-49 years in prostate cancer (SIR=2.59, 95% CI 1.34 to 4.52) and skin melanoma (SIR=1.62, 95% CI 1.14 to 2.23), while there was almost no excess in the older ages. By contrast, an increased risk, mainly in ages of 70 years and higher, was observed for non-melanoma skin cancer (SIR=1.40, 95% CI 1.10 to 1.76), multiple myeloma (SIR=1.69, 95% CI 1.08 to 2.51), adenocarcinoma of the lung (SIR=1.90, 95% CI 1.34 to 2.62), and mesothelioma (SIR=2.59, 95% CI 1.24 to 4.77). By contrast with earlier studies, the incidence of testicular cancer was decreased (SIR=0.51, 95% CI 0.23 to 0.98).

CONCLUSIONS

Some of these associations have been observed previously, and potential exposure to polycyclic aromatic hydrocarbons, asbestos and shift work involving disruption of circadian rhythms may partly explain these results.

[Discovered roles of MLL in pathogenesis of multiple myeloma]

Multiple myeloma is one of incurable hematological malignancies and targeted therapies for novel oncogenes are to be exploited. Analyses of multiple myeloma patients revealed that HOXA9 was overexpressed in patients lacking known IgH translocation and it was evaluated as a candidate oncogene in multiple myeloma. This overexpression of HOXA9 was supposed to be due to dysfunction of histone methyltransferases (HMT) and mutations in MLL encoding HMT were found. Panobinostat, an HDAC inhibitor is currently undergoing preclinical and clinical evaluation as a novel drug for multiple myeloma. We found that panobinostat suppresses expression of MLL protein through modulation of its stability as well as Hsp90 inhibitor. More precise roles of MLL in pathogenesis of multiple myeloma are to be elucidated.

Alcohol consumption has a protective effect against hematological malignancies: a population-based study in Sweden including 420,489 individuals with alcohol use disorders

BACKGROUND

It has been suggested that alcohol consumption is associated with increased risk of a few solid cancers, although studies that examined the association with hematological malignancies have shown inconsistent results. In this study, we examined the risk of hematological malignancies among individuals who had alcohol use disorders (AUDs) in Sweden.

METHODS

Individuals with AUDs were identified from the nationwide Swedish Hospital Discharge Register and Outpatient Register, the Crime Register, and the Prescription Drug Register, and they were linked to the Swedish Cancer Registry to calculate standardized incidence ratios (SIRs) of hematological malignancies, using those Swedes without AUDs as a reference. In addition, we used a quasi-experimental sibling design to investigate the odds ratios among sibling pairs who were discordant with AUDs.

RESULTS

A total of 420,489 individuals were identified with AUDs. After more than 15 million person-years of follow-up, a total of 1755 individuals developed hematological malignancies demonstrating a low risk, i.e., SIR = 0.60 (95% confidence interval = 0.57-0.63). People with AUDs had low risks for developing specific types of malignancies. The lowest risk (0.51) was for leukemia, followed by myeloma (0.52), non-Hodgkin lymphoma (0.65), and Hodgkin disease (0.71). The risk was lower among AUDs identified at an older age. The low risks of hematological malignancies were also noted using sibling analysis.

CONCLUSIONS

Our data suggest that alcohol consumption has a protective effect against hematological malignancies. However, further studies are needed to identity the underlying mechanisms of the protective effect of alcohol consumption against hematological malignancies.

Lymphohematopoietic Malignancies and Oil Exploitation in Koprivnica-Krizevci County, Croatia

To determine lymphohematopoietic malignancy incidence rates between populations living near oil-gas fields (two regions) compared with those living in areas free from oil-gas exploitation (one region) in Koprivnica-Krizevci County, Croatia, 803 new cases of lymphohematopoietic malignancies were studied for two time periods: 1971-1980 (prior to oil-gas exploitation) and 1981-2000 (during oil-gas exploitation). The results showed considerable geographic differences in the incidences of chronic myeloid leukemia and multiple myeloma. The authors conclude that proximity to oil or gas fields represents an increased population risk of developing lymphohematopoietic cancers.

Anthropometric, behavioral, and female reproductive factors and risk of multiple myeloma: a pooled analysis

BACKGROUND

Risk of developing multiple myeloma (MM) rises with age and is greater among men and blacks than among women and whites, respectively, and possibly increased among obese persons. Other risk factors remain poorly understood. By pooling data from two complementary epidemiologic studies, we assessed whether obesity, smoking, or alcohol consumption alters MM risk and whether female reproductive history might explain the lower occurrence of MM in females than in males.

METHODS

The Los Angeles County MM Case-Control Study (1985-1992) included 278 incident cases and 278 controls, matched on age, sex, race, and neighborhood of residence at case's diagnosis. We estimated MM risk using conditional logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). In the prospective California Teachers Study (CTS), 152 women were diagnosed with incident MM between 1995 and 2009; we calculated hazard ratios using Cox proportional hazards analysis. Data from the two studies were pooled using a stratified, nested case-control sampling scheme (10:1 match) for the CTS; conditional logistic regression among 430 cases and 1,798 matched controls was conducted.

RESULTS

Obesity and smoking were not associated with MM risk in the individual or combined studies. Alcohol consumption was associated with decreased MM risk among whites only (pooled OR = 0.66, 95% CI = 0.49-0.90) for ever versus never drinking. Higher gravidity and parity were associated with increased MM risk, with pooled ORs of 1.38 (95 % CI = 1.01-1.90) for ≥3 versus 1-2 pregnancies and 1.50 (95% CI = 1.09-2.06) for ≥3 versus 1-2 live births.

CONCLUSIONS

Female reproductive history may modestly alter MM risk, but appears unlikely to explain the sex disparity in incidence. Further investigation in consortial efforts is warranted.

Multiple myeloma and occupation: a pooled analysis by the International Multiple Myeloma Consortium

OBJECTIVE

We investigated occupational risk of multiple myeloma (MM) in a pooled analysis of five international case-control studies.

METHODS

We calculated the odds ratio and its 95% confidence interval for selected occupations with unconditional regression analysis in 1959 MM cases and 6192 controls, by pooling study-specific risks using random-effects meta-analysis. Exposure to organic solvents was assessed with a job-exposure matrix (JEM).

RESULTS

Gardeners and nursery workers combined, most likely exposed to pesticides, showed a 50% increase in risk (OR = 1.50, 95% CI 0.9-2.3), while other farming jobs did not. Metal processors (OR = 1.55, 95% CI 0.9-2.3), female cleaners (OR = 1.32, 95% CI 1.0-1.8), and high level exposure to organic solvents (OR = 1.38, 95% CI 0.96-1.8) also showed moderately increased risks.

CONCLUSIONS

Additional case-control studies of MM aetiology are warranted to further investigate the nature of the repeatedly reported increase in MM risk in several occupational groups.

Body mass index and physical activity at different ages and risk of multiple myeloma in the NIH-AARP diet and health study

Several studies have reported an increased risk of multiple myeloma associated with excess body weight. We investigated the risk of multiple myeloma in relation to separate measures of adiposity and energy balance at different ages in the National Institutes of Health-AARP Diet and Health Study, a large prospective cohort study in the United States. Participants completed a baseline questionnaire (1995-1996; n = 485,049), and a subset of participants completed a second questionnaire (1996-1997; n = 305,618) in which we solicited more detailed exposure information. Hazard ratios and 95% confidence intervals were estimated for the risk of multiple myeloma (overall, n = 813; subset, n = 489) in relation to several measures of obesity and leisure time physical activity. Multiple myeloma risk was associated with increasing body mass index (BMI) at cohort entry (per 5-kg/m(2) increase, hazard ratio (HR) = 1.10, 95% confidence interval (CI): 1.00, 1.22); similar associations were observed for BMI at age 50 years (HR = 1.14, 95% CI: 1.02, 1.28), age 35 years (HR = 1.20, 95% CI: 1.05, 1.36), and age 18 years (HR = 1.13, 95% CI: 0.98, 1.32) without adjustment for baseline BMI. Risk of multiple myeloma was not associated with physical activity level at any age. These findings support the hypothesis that excess body weight, both in early adulthood and later in life, is a risk factor for multiple myeloma and suggest that maintaining a healthy body weight throughout life may reduce multiple myeloma risk.

Primary cutaneous plasmacytoma occurring after pacemaker implantation and recurring in scar tissue

Primary cutaneous plasmacytomas are rare and little is known about their treatment and progression. We describe for the first time the predilection of primary cutaneous plasmacytoma to occur in a scar or sites of trauma. We report an 89-year-old man who presented with a slowly expanding asymptomatic mass over his pacemaker implantation, 1 year after insertion. Further investigation ruled out multiple myeloma and histology confirmed it to be a cutaneous plasmacytoma. This was treated successfully by local radiotherapy after extraction of the pacemaker and implantation of a new pacemaker on the opposite side. The patient subsequently developed an additional cutaneous plasmacytoma over the new pacemaker site, followed by the development of progressive multiple myeloma. Primary cutaneous plasmacytoma can show predilection for sites of trauma or surgery. Surgical excision of the plasmocytoma and local radiotherapy may be a reasonable strategy in the first initially after pacemaker removal.

Multiple unrelated malignancies following renal transplantation: an evaluation of four cases

The risk of de novo malignancy is significantly higher in patients who have undergone organ transplantation than in the general population. Long-term immunosuppressive treatment, in addition to age, genetic predisposition and infectious agents, plays a major role in the development of malignancy. Although skin and hemopoietic system cancers are common, atypical presentations of malignancies may occasionally be seen during long-term follow-up in patients with functioning allografts. In this report, four cases, each with more than one different primary malignancy (one patient with three malignancies and three patients with two malignancies), are presented.

Monoclonal gammopathy of undetermined significance and smoldering multiple myeloma: biological insights and early treatment strategies

After decades of virtually no progress, multiple myeloma survival has improved significantly in the past 10 years. Indeed, multiple myeloma has perhaps seen more remarkable progress in treatment and patient outcomes than any other cancer during the last decade. Recent data show that multiple myeloma is consistently preceded by a precursor state (monoclonal gammopathy of undetermined significance [MGUS]/smoldering multiple myeloma [SMM]). This observation provides a framework for prospective studies focusing on transformation from precursor disease to multiple myeloma and for the development of treatment strategies targeting "early myeloma." This review discusses current biological insights in MGUS/SMM, provides an update on clinical management, and discusses how the integration of novel biological markers, molecular imaging, and clinical monitoring of MGUS/SMM could facilitate the development of early treatment strategies for high-risk SMM (early myeloma) patients in the future.

Multiple myeloma among Chornobyl accident clean-up workers - state and perspectives of analytical study

The objective of the study was to analyze the Multiple Myeloma (MM) incidence in clean-up workers preparing the information background for consequent analytical study with a dose-dependent risk estimates.

MATERIALS AND METHODS

The Cohort Database was linked to the Ukrainian National Cancer Registry to identify the MM cases in a cohort of 152 520 male clean-up workers.

RESULTS

The 64 MM cases were identified in the studied Cohort for the 1987-2012 period. Fifty-eight of them were included to the preliminary incidence analysis accounting for the 10-years lag-period. According to the preliminary data analysis the MM incidence rate in studied clean-up workers Cohort did not exceed the corresponding rate in general population of Ukraine along the 21 years after the catastrophe.

CONCLUSIONS

Standardized incidence ratio for the 2008-2012 period, that is 22-26 years after the accident, demonstrated the significant excess of MM incidence among male clean-up workers in comparison with general population of Ukraine of corresponding age and gender (SIR 1.61, 95% CI 1.01;2.21).

Novel players in multiple myeloma pathogenesis: role of protein kinases CK2 and GSK3

Multiple myeloma (MM) is an incurable plasma cell malignancy, which causes a significant morbidity due to organ damage and bone tissue destruction. In recent years, novel drugs have become available for MM therapy thanks to a more deepened knowledge of this disease's pathogenesis. The perspective of employing targeted therapies has considerably changed the expectations on the clinical outcome for patients affected by this malignancy and among the targetable molecules identified for MM therapy are several protein kinases, which have been proven to play relevant roles in supporting malignant plasma cell growth by regulating critical signaling cascades and by sustaining oncogenic mechanisms. Protein kinase CK2 (formerly known as casein kinase 2) and GSK3 (glycogen synthase kinase 3) are two multifaceted serine-threonine kinases whose task in the pathogenesis of malignant cell growth is increasingly emerging both in solid and blood tumors. In hematologic malignancies, CK2 and GSK3 have been shown to play an oncogenic function in chronic and acute leukemias as well as in MM. They have been demonstrated to act by impinging on pivotal signaling pathways that control malignant clone growth. We will herein briefly review the more recent advancements on the role of these two kinases in regulating the NF-κB, STAT3 and endoplasmic reticulum (ER) stress/unfolded protein response (UPR) signaling in MM and discuss the rationale of using small selective inhibitors as a therapeutic strategy to hamper the growth of malignant plasma cells or to improve the MM-associated bone disease.