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Boquoi A, Banahan SM, Mohring A, Savickaite I, Strapatsas J, Hildebrandt B, Kobbe G, Gattermann N, Haas R, Schroeder T, Germing U, Fenk R. Therapy-related myeloid neoplasms following treatment for multiple myeloma-a single center analysis. Ann Hematol 2022; 101:1031-1038. [PMID: 35262868 PMCID: PMC8993729 DOI: 10.1007/s00277-022-04775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 01/25/2022] [Indexed: 11/25/2022]
Abstract
Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) can be late complications following mutagenic treatment. Limited data is available on the outcome of patients developing therapy-related MDS and AML after treatment for multiple myeloma (MM). We identified 250 patients with therapy-associated MDS or AML in the Duesseldorf MDS registry. Of those, 50 patients were previously diagnosed with multiple myeloma (mm-MDS/AML). We compared them to patients with de novo MDS (n = 4862) and to patients with MDS following other underlying diseases (tMDS) (n = 200). mm-MDS patients and tMDS patients showed similar karyotypes and degrees of cytopenia. However, mm-MDS patients had significantly higher blast counts and more often belonged to the high-risk group according to the International Prognostic Scoring System (IPSS) (both p < 0.05). Although the rate of progression to AML was similar in mm-MDS and tMDS, both transformed significantly more often than de novo MDS (p < 0.05). Median overall survival of patients with mm-MDS (13 months; range: 1–99) and tMDS (13 months; range 0–160) was also similar yet significantly shorter than patients with de novo MDS (32 months; range 0–345 months; p < 0.05). Furthermore, survival of mm-MDS patients was not affected by myeloma activity. Despite significantly more high-risk disease and higher blast cell counts, myeloma-associated MDS-patients show features akin to other tMDS. Survival is similar to other tMDS and irrespective of myeloma remission status or transformation to AML. Thus, patient outcome is not determined by competing clones but rather by MDS governing the stem cell niche.
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Affiliation(s)
- A Boquoi
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany.
| | - S M Banahan
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - A Mohring
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - I Savickaite
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - J Strapatsas
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - B Hildebrandt
- Institute of Human Genetics, Heinrich-Heine-University, Duesseldorf, Germany
| | - G Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - N Gattermann
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - R Haas
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - T Schroeder
- Department of Hematology and Stem Cell Transplantation, University Medicine Essen, Essen, Germany
| | - U Germing
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - R Fenk
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
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Perez I, Schinke C, Pina-Oviedo S, Alapat D. Synchronous plasma cell neoplasm and B lymphoblastic leukemia/lymphoma at initial presentation: first report of an unusual association with a good outcome. J Hematop 2022; 15:29-34. [PMID: 38358598 DOI: 10.1007/s12308-021-00480-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022] Open
Abstract
A synchronous diagnosis of a plasma cell neoplasm (PCN) and a non-plasma cell hematologic malignancy is very rare. We report what we believe is the first instance of a synchronous PCN and B lymphoblastic leukemia/lymphoma (B-ALL) diagnosed at initial presentation. The patient underwent laboratory evaluation for an underlying plasma cell neoplasm, including immunology studies, bone marrow biopsy, and flow cytometry immunophenotyping. Serum lambda free light chain and serum IgG were elevated, with an IgG lambda M-protein identified by serum protein electrophoresis and immunofixation. The clinical working diagnosis was plasma cell myeloma. Bone marrow biopsy was positive for a composite PCN and B-ALL. The patient received treatment with VDT-PACE chemotherapy followed by autologous stem cell transplant and maintenance therapy with bortezomib/daratumumab and is in complete remission for both diseases 3.5 years after diagnosis. This case not only adds to the known repertoire of hematologic neoplasms that can occur in association to a PCN, but also demonstrates that patients presenting with this rare combination of hematopoietic neoplasms can be effectively treated simultaneously with excellent responses. Additional research is warranted to understand the pathophysiology, to identify potential prognostic factors, and to develop specific therapeutic plans for these patients.
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Affiliation(s)
- Ivette Perez
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Carolina Schinke
- Myeloma Center, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sergio Pina-Oviedo
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, 4301 W. Markham St. # 502, Little Rock, AR, 72205, USA.
| | - Daisy Alapat
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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[Clinical characteristics of patients with multiple myeloma harboring 6q deletion]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:642-645. [PMID: 34547869 PMCID: PMC8501288 DOI: 10.3760/cma.j.issn.0253-2727.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Objective: To study the clinical and cytogenetic characteristics of patients with multiple myeloma harboring 6q deletion, with the aim to determine the impact of 6q deletion on survival. Methods: This study included the retrospective analysis of 382 newly diagnosed patients with multiple myeloma in our hospital from 2014 to 2017 and compared the clinical and cytogenetic characteristics between patients with and without 6q deletion. The log-rank test and the Cox proportional hazards regression model were used to analyze prognostic factors for progression-free survival (PFS) and overall survival (OS) . Results: Compared to those without 6q, the patients with 6q deletion were older (median age, 63 vs 58 years, P=0.039) , had higher incidence of t (4; 14) (30.4% vs 16.4% , P=0.020) , and higher proportion of complex karyotypes (22.2% vs 5.3% , P=0.001) . Univariate survival analysis using the log-rank test revealed that 6q deletion was associated with shorter PFS. However, by the Cox multivariate proportional hazards regression model, 6q deletion was not an independent prognostic factor and its effect on survival was affected by age, t (4; 14) , and other risk factors. Conclusions: 6q deletion was common in elderly patients with multiple myeloma and was often accompanied by t (4;14) and complex karyotypes. However, 6q deletion was not an independent prognostic factor for multiple myeloma.
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Hamdaoui H, Benlarroubia O, Ait Boujmia OK, Mossafa H, Ouldim K, Belkhayat A, Smyej I, Benrahma H, Dehbi H, Chegdani F. Cytogenetic and FISH analysis of 93 multiple myeloma Moroccan patients. Mol Genet Genomic Med 2020; 8:e1363. [PMID: 32573970 PMCID: PMC7507047 DOI: 10.1002/mgg3.1363] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 12/17/2022] Open
Abstract
Background Multiple myeloma (MM) is a disease characterized by heterogeneous clinical presentations as well as complex genetic and molecular abnormalities. In MM, cytogenetic analysis is a challenge because of the low proliferation of malignant plasma cells. Thus, interphase fluorescence in situ hybridization (FISH), performed on sorted plasma cells detected abnormalities independently of a proliferative and infiltrative index. The purpose of this study was to explore, for the first time, the cytogenetic and molecular genetics features in Moroccan patients with multiple myeloma referred exclusively to National Reference Laboratory and to determine their risk stratification based on these features. Methods We performed cytogenetic analysis on 93 MM cases, all patients were subjected to FISH analysis, among which 45 patients have benefited from both FISH analysis and standard karyotype. Results Karyotype was normal in 78% (35/45) while, it was complex with varied structural and numerical abnormalities in 22% (10/45) of all patients, among which Hyperdiploid karyotype was found in 9% (n = 4 cases) and nonhyperdiploid in 13% (n = 6 cases). The most common numerical abnormalities were gains of chromosomes 3, 5, 9, 15, and 19. Whole chromosome losses were also frequent, affecting chromosomes X, 3, 14, 16 and 22. FISH analysis detected abnormalities in 50% of cases. The translocation t(4;14) and dup (1q) were the most frequent types of anomalies (14% and 13% respectively), followed by (17p) deletion and 14q32/IGH translocations with an undetermined origin (12% each) then the (1p) deletion (4%). For the normal karyotypes, FISH revealed chromosome abnormalities in 46%. Conclusion This study compares the results of cytogenetic analysis of chromosomal abnormalities in the Moroccan population with other countries. ½ patient showed at least one type of molecular genetic abnormalities. Therefore, the introducing of the cytogenetic analysis is obligatory in the diagnosis of multiple myeloma.
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Affiliation(s)
- Hasna Hamdaoui
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco.,Laboratory of Health and Environment, Faculty of Sciences Ain Chock, University Hassan II, Casablanca, Morocco
| | - Oumaima Benlarroubia
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Oum Kaltoum Ait Boujmia
- Laboratory of Cellular and Molecular Pathology, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II, Casablanca, Morocco
| | - Hossein Mossafa
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Karim Ouldim
- Faculty of Medicine and Pharmacy, Medical Genetics and Oncogenetics Unit, Sidi Mohamed Ben Abdellah University, Fes, Morocco
| | - Aziza Belkhayat
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Imane Smyej
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Houda Benrahma
- National Reference Laboratory, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco.,Faculty of Medicine, Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - Hind Dehbi
- Laboratory of Cellular and Molecular Pathology, Faculty of Medicine and Pharmacy of Casablanca, University Hassan II, Casablanca, Morocco
| | - Fatima Chegdani
- Laboratory of Health and Environment, Faculty of Sciences Ain Chock, University Hassan II, Casablanca, Morocco
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Aydin C, Ulas T, Hangul C, Yucel OK, Iltar U, Salim O, Ekinci D, Berker Karauzum S. Conventional Cytogenetics and Interphase Fluorescence In Situ Hybridization Results in Multiple Myeloma: A Turkey Laboratory Analysis of 381 Cases. Indian J Hematol Blood Transfus 2020; 36:284-291. [PMID: 32425379 PMCID: PMC7229081 DOI: 10.1007/s12288-019-01215-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 10/12/2019] [Indexed: 12/16/2022] Open
Abstract
Multiple myeloma (MM) is an uncontrolled proliferation of plasma cells and these cells play an important role in the immune system. In this research, we retrospectively analyzed cytogenetic abnormalities in 381 patients with MM. Conventional cytogenetic analysis was successful in 354 patients (92.9%). Chromosomal abnormalities were detected in 31.9% (113/354) and 45.8% (116/253) of patients screened with conventional cytogenetics and FISH, respectively. Of 113 patients with chromosomal abnormalities, 31 patients (27.4%) had hyperdiploid and 26 of 31 patients with hyperdiploidy had both numerical and structural anomalies. On the other hand, non-hyperdiploidy was observed in 62 patients (54.8%). The most common gains of chromosomes were 15, 9, 19 followed by 3, 5, 11, and 21. Whole chromosome losses were also frequent involving Y, 13 and 22 chromosomes. In our patients, 1q gain was determined in a total of 25 patients (22%), including 7 structural abnormalities and 19 unbalanced translocations causing complete or partial duplication of the long arm of chromosome 1. Although the breakpoints were different, t(1;5) balanced translocation and unbalanced translocations of t(1;2), t(1;3), t(1;7), t(1;16) and t(1;19) were observed twice. The most common structural abnormality was the deletion of the short arm of chromosome 13 (13q) or monosomy of chromosome 13 (-13) (24.1%, 61/253) in patients evaluated by FISH. Deletion involving chromosome 17p (del 17p) or monosomy of chromosome 17 (-17) were found in 31 (12.3%) patients. Translocations involving IgH regions were as follows: t(11;14)(q13;q32.33) in 22 (8.7%), t(4;14)(p16.3;q32.33) in 22 (8.7%) and t(14;16)(q32.33;q23.1) in 2 (0.8%) patients. In addition, t(14;17)(q32;q21) translocation was detected in a multiple myeloma patient for the first time in this study. There are a limited number of large study groups including both cytogenetic and FISH findings in MM patients. As the number of these studies increases, it is thought that new cytogenetic data can be guiding especially in clinical risk determination.
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Affiliation(s)
- Cigdem Aydin
- Bucak School of Health, Mehmet Akif Ersoy University, Burdur, Turkey
| | - Turgay Ulas
- Department of Hematology, Faculty of Medicine, Near East University, Nicosia, Cyprus
| | - Ceren Hangul
- Department of Medical Biology and Genetics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Orhan Kemal Yucel
- Department of Hematology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Utku Iltar
- Department of Hematology, Antalya Training and Research Hospital, University of Health Sciences, Antalya, Turkey
| | - Ozan Salim
- Department of Hematology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Deniz Ekinci
- Department of Hematology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Sibel Berker Karauzum
- Department of Medical Biology and Genetics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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6
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Hyperhaploid plasma cell myeloma characterized by poor outcome and monosomy 17 with frequently co-occurring TP53 mutations. Blood Cancer J 2019; 9:20. [PMID: 30783078 PMCID: PMC6381150 DOI: 10.1038/s41408-019-0182-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/18/2019] [Accepted: 01/30/2019] [Indexed: 01/20/2023] Open
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7
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Cordas Dos Santos DM, Eilers J, Sosa Vizcaino A, Orlova E, Zimmermann M, Stanulla M, Schrappe M, Börner K, Grimm D, Muckenthaler MU, Kulozik AE, Kunz JB. MAP3K7 is recurrently deleted in pediatric T-lymphoblastic leukemia and affects cell proliferation independently of NF-κB. BMC Cancer 2018; 18:663. [PMID: 29914415 PMCID: PMC6006985 DOI: 10.1186/s12885-018-4525-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 05/18/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Deletions of 6q15-16.1 are recurrently found in pediatric T-cell acute lymphoblastic leukemia (T-ALL). This chromosomal region includes the mitogen-activated protein kinase kinase kinase 7 (MAP3K7) gene which has a crucial role in innate immune signaling and was observed to be functionally and prognostically relevant in different cancer entities. Therefore, we correlated the presence of MAP3K7 deletions with clinical parameters in a cohort of 327 pediatric T-ALL patients and investigated the function of MAP3K7 in the T-ALL cell lines CCRF-CEM, Jurkat and MOLT-4. METHODS MAP3K7 deletions were detected by multiplex ligation-dependent probe amplification (MLPA). T-ALL cell lines were transduced with adeno-associated virus (AAV) vectors expressing anti-MAP3K7 shRNA or a non-silencing shRNA together with a GFP reporter. Transduction efficiency was measured by flow cytometry and depletion efficiency by RT-PCR and Western blots. Induction of apoptosis was measured by flow cytometry after staining with PE-conjugated Annexin V. In order to assess the contribution of NF-κB signaling to the effects of MAP3K7 depletion, cells were treated with TNF-α and cell lysates analyzed for components of the NF-κB pathway by Western blotting and for expression of the NF-κB target genes BCL2, CMYC, FAS, PTEN and TNF-α by RT-PCR. RESULTS MAP3K7 is deleted in approximately 10% and point-mutated in approximately 1% of children with T-ALL. In 32 of 33 leukemias the deletion of MAP3K7 also included the adjacent CASP8AP2 gene. MAP3K7 deletions were associated with the occurrence of SIL-TAL1 fusions and a mature immunophenotype, but not with response to treatment and outcome. Depletion of MAP3K7 expression in T-ALL cell lines by shRNAs slowed down proliferation and induced apoptosis, but neither changed protein levels of components of NF-κB signaling nor NF-κB target gene expression after stimulation with TNF-α. CONCLUSIONS This study revealed that the recurrent deletion of MAP3K7/CASP8AP2 is associated with SIL-TAL1 fusions and a mature immunophenotype, but not with response to treatment and risk of relapse. Homozygous deletions of MAP3K7 were not observed, and efficient depletion of MAP3K7 interfered with viability of T-ALL cells, indicating that a residual expression of MAP3K7 is indispensable for T-lymphoblasts.
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Affiliation(s)
- David M Cordas Dos Santos
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Juliane Eilers
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Alfonso Sosa Vizcaino
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Elena Orlova
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, MH Hannover, Hannover, Germany
| | - Martin Stanulla
- Department of Pediatric Hematology and Oncology, MH Hannover, Hannover, Germany
| | - Martin Schrappe
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Kathleen Börner
- Department of Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany.,German Center for Infection Research (DZIF), Partner Site Heidelberg, Heidelberg, Germany.,BioQuant Center, Heidelberg University, Heidelberg, Germany
| | - Dirk Grimm
- Department of Infectious Diseases, Virology, Heidelberg University Hospital, Heidelberg, Germany.,German Center for Infection Research (DZIF), Partner Site Heidelberg, Heidelberg, Germany.,BioQuant Center, Heidelberg University, Heidelberg, Germany.,Cluster of Excellence CellNetworks, Heidelberg University, Heidelberg, Germany
| | - Martina U Muckenthaler
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany
| | - Andreas E Kulozik
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany.,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany.,German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Joachim B Kunz
- Department of Pediatric Oncology, Hematology, Immunology and Pulmonology, Heidelberg University Children's Hospital, Heidelberg, Germany. .,Molecular Medicine Partnership Unit (MMPU), Heidelberg, Germany. .,German Cancer Consortium (DKTK), Heidelberg, Germany.
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Abstract
Multiple myeloma (MM), a type of malignant tumor, is characterized by dysplasia of clonal plasma cells in the bone marrow. People with MM will have damaged organs or tissues due to secretion of large amounts of monoclonal immunoglobulin or fragments (M protein). Despite improved survivability by novel treatment strategies over the last decade, MM is still incurable by current therapies. Long noncoding RNAs (lncRNAs), with length of more than 200 nucleotides, have been reported to act as important regulators in many diseases, including MM. Recent studies have reported aberrant lncRNA expression in MM; these dysregulated lncRNAs can play oncogenic and/or tumor-suppressive roles in the development and progression of MM. In this article, we present a general overview on the role of lncRNAs in MM pathogenesis and discuss their potential as prognostic biomarkers and targets for treatment.
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Affiliation(s)
- Hui Meng
- *Department of Medical Laboratory, Wuhan General Hospital of PLA, Wuhan, P.R. China
| | - Lei Han
- †Discipline Section of Medical Department, Wuhan General Hospital of PLA, Wuhan, P.R. China
| | - Chun Hong
- *Department of Medical Laboratory, Wuhan General Hospital of PLA, Wuhan, P.R. China
| | - Jinya Ding
- *Department of Medical Laboratory, Wuhan General Hospital of PLA, Wuhan, P.R. China
| | - Qianchuan Huang
- *Department of Medical Laboratory, Wuhan General Hospital of PLA, Wuhan, P.R. China
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The Mutational Landscape of Circulating Tumor Cells in Multiple Myeloma. Cell Rep 2017; 19:218-224. [PMID: 28380360 PMCID: PMC5439509 DOI: 10.1016/j.celrep.2017.03.025] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 12/29/2016] [Accepted: 03/06/2017] [Indexed: 01/22/2023] Open
Abstract
The development of sensitive and non-invasive “liquid biopsies” presents new opportunities for longitudinal monitoring of tumor dissemination and clonal evolution. The number of circulating tumor cells (CTCs) is prognostic in multiple myeloma (MM), but there is little information on their genetic features. Here, we have analyzed the genomic landscape of CTCs from 29 MM patients, including eight cases with matched/paired bone marrow (BM) tumor cells. Our results show that 100% of clonal mutations in patient BM were detected in CTCs and that 99% of clonal mutations in CTCs were present in BM MM. These include typical driver mutations in MM such as in KRAS, NRAS, or BRAF. These data suggest that BM and CTC samples have similar clonal structures, as discordances between the two were restricted to subclonal mutations. Accordingly, our results pave the way for potentially less invasive mutation screening of MM patients through characterization of CTCs.
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10
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Gu C, Feng L, Peng H, Yang H, Feng Z, Yang Y. MTDH is an oncogene in multiple myeloma, which is suppressed by Bortezomib treatment. Oncotarget 2016; 7:4559-69. [PMID: 26683226 PMCID: PMC4826226 DOI: 10.18632/oncotarget.6610] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 11/26/2015] [Indexed: 12/19/2022] Open
Abstract
Metadherin (MTDH) is identified as an oncogene in multiple cancers including breast cancer, bladder cancer and endometrial cancer. However, the function of MTDH in multiple myeloma (MM) is still unexplored. In this study, we disclose that MTDH is an oncogene in MM. This is characterized by an elevation mRNA level of MTDH and chromosomal gain of MTDH locus in MM cells compared to normal samples. Moreover, MTDH expression significantly increased in MMSET translocation (MS) subgroup, one of the high-risk subgroups in MM, and was significantly correlated with MM patients' poor outcomes in Total Therapy 2 (TT2) cohort. Further knockdown of MTDH expression by shRNA in MM cells induced cell apoptosis, inhibited MM cells growth in vitro and decreased xenograft tumor formation in vivo. Interestingly, opposite to TT2, MM patients with high-MTDH expression showed favorable survival outcomes in the TT3 cohort, while Bortezomib treatment was the major difference between TT2 and TT3 cohort. Furthermore we proved that Bortezomib suppressed pre- and post-transcription levels of MTDH expression of MM cells in vitro and in vivo. Finally, our studies demonstrated that MTDH is a transcriptional gene of MMSET/NFκB /MYC signaling in MM cells, which is inhibited by Bortezomib treatment.
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Affiliation(s)
- Chunyan Gu
- Department of Pathology, Nanjing Medical University, 210029, Nanjing, China.,Basic Medical College, Nanjing University of Chinese Medicine, 210046, Nanjing, China.,Department of Pathology, University of Iowa Carver College of Medicine, 52242, Iowa City, IA, USA
| | - Lang Feng
- Department of Urology, Beijing Friendship Hospital, Capital Medical University, 100050, Beijing, China.,Department of Urology, University of Iowa Carver College of Medicine, 52242, Iowa City, IA, USA
| | - Hailin Peng
- Department of Laboratory Medicine, Taizhou people's hospital, 225300, Taizhou, China
| | - Hongbao Yang
- Center for New Drug Safety Evaluation and Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Zhenqing Feng
- Department of Pathology, Nanjing Medical University, 210029, Nanjing, China
| | - Ye Yang
- Basic Medical College, Nanjing University of Chinese Medicine, 210046, Nanjing, China.,Department of Internal Medicine, University of Iowa Carver College of Medicine, 52242, Iowa City, IA, USA
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11
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Hyperhaploidy is a novel high-risk cytogenetic subgroup in multiple myeloma. Leukemia 2016; 31:637-644. [PMID: 27694925 DOI: 10.1038/leu.2016.253] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 07/20/2016] [Accepted: 08/19/2016] [Indexed: 12/13/2022]
Abstract
Hyperhaploid clones (24-34 chromosomes) were identified in 33 patients with multiple myeloma (MM), demonstrating a novel numerical cytogenetic subgroup. Strikingly, all hyperhaploid karyotypes were found to harbor monosomy 17p, the single most important risk stratification lesion in MM. A catastrophic loss of nearly a haploid set of chromosomes results in disomies of chromosomes 3, 5, 7, 9, 11, 15, 18, 19 and 21, the same basic set of odd-numbered chromosomes found in trisomy in hyperdiploid myeloma. All other autosomes are found in monosomy, resulting in additional clinically relevant monosomies of 1p, 6q, 13q and 16q. Hypotriploid subclones (58-68 chromosomes) were also identified in 11 of the 33 patients and represent a duplication of the hyperhaploid clone. Analysis of clones utilizing interphase fluorescence in situ hybridization (iFISH), metaphase FISH and spectral karyotyping identified either monosomy 17 or del17p in all patients. Amplification of 1q21 was identified in eight patients, demonstrating an additional high-risk marker. Importantly, our findings indicate that current iFISH strategies may be uninformative or ambiguous in the detection of these clones, suggesting this patient subgroup maybe underreported. Overall survival for patients with hyperhaploid clones was poor, with a 5-year survival rate of 23.1%. These findings identify a distinct numerical subgroup with cytogenetically defined high-risk disease.
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12
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Mikulasova A, Smetana J, Wayhelova M, Janyskova H, Sandecka V, Kufova Z, Almasi M, Jarkovsky J, Gregora E, Kessler P, Wrobel M, Walker BA, Wardell CP, Morgan GJ, Hajek R, Kuglik P. Genomewide profiling of copy-number alteration in monoclonal gammopathy of undetermined significance. Eur J Haematol 2016; 97:568-575. [PMID: 27157252 DOI: 10.1111/ejh.12774] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2016] [Indexed: 12/23/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a benign condition with an approximate 1% annual risk of symptomatic plasma cell disorder development, mostly to multiple myeloma (MM). We performed genomewide screening of copy-number alterations (CNAs) in 90 MGUS and 33 MM patients using high-density DNA microarrays. We identified CNAs in a smaller proportion of MGUS (65.6%) than in MM (100.0%, P = 1.31 × 10-5 ) and showed median number of CNAs is lower in MGUS (3, range 0-22) than in MM (13, range 4-38, P = 1.82 × 10-10 ). In the MGUS cohort, the most frequent losses were located at 1p (5.6%), 6q (6.7%), 13q (30.0%), 14q (14.4%), 16q (8.9%), 21q (5.6%), and gains at 1q (23.3%), 2p (6.7%), 6p (13.3%), and Xq (7.8%). Hyperdiploidy was detected in 38.9% of MGUS cases, and the most frequent whole chromosome gains were 3 (25.6%), 5 (23.3%), 9 (37.8%), 15 (23.3%), and 19 (32.2%). We also identified CNAs such as 1p, 6q, 8p, 12p, 13q, 16q losses, 1q gain and hypodiploidy, which are potentially associated with an adverse prognosis in MGUS. In summary, we showed that MGUS is similar to MM in that it is a genetically heterogeneous disorder, but overall cytogenetic instability is lower than in MM, which confirms that genetic abnormalities play important role in monoclonal gammopathies.
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Affiliation(s)
- Aneta Mikulasova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jan Smetana
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic
| | - Marketa Wayhelova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic
| | - Helena Janyskova
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic
| | - Viera Sandecka
- Department of Internal Medicine, Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | - Zuzana Kufova
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Martina Almasi
- Department of Clinical Hematology, University Hospital Brno, Brno, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Evzen Gregora
- Department of Internal Medicine and Hematology, University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kessler
- Department of Hematology and Transfusion, General Hospital, Pelhrimov, Czech Republic
| | - Marek Wrobel
- Department of Oncology, Hospital Novy Jicin, Novy Jicin, Czech Republic
| | - Brian A Walker
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Christopher P Wardell
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,Laboratory for Genome Sequencing Analysis, RIKEN Center for Integrative Medical Sciences, Tokyo, Japan
| | - Gareth J Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Roman Hajek
- Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic.,Department of Hematooncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Petr Kuglik
- Department of Experimental Biology, Faculty of Science, Masaryk University, Brno, Czech Republic.,Department of Medical Genetics, University Hospital Brno, Brno, Czech Republic.,Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
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13
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NEK2 mediates ALDH1A1-dependent drug resistance in multiple myeloma. Oncotarget 2015; 5:11986-97. [PMID: 25230277 PMCID: PMC4322982 DOI: 10.18632/oncotarget.2388] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 08/23/2014] [Indexed: 12/30/2022] Open
Abstract
We reported previously that increased expression of aldehyde dehydrogenase 1 (ALDH1) in multiple myeloma (MM) is a marker of tumor-initiating cells (TICs) that is further associated with chromosomal instability (CIN). Here we demonstrate that member A1 of the ALDH1 family of proteins, ALDH1A1, is most abundantly expressed in myeloma. Enforced expression of ALDH1A1 in myeloma cells led to increased clonogenicity, tumor formation in mice, and resistance to myeloma drugs in vitro and in vivo. The mechanism underlying these phenotypes included the ALDH1A1-dependent activation of drug-efflux pump, ABCB1, and survival proteins, AKT and BCL2. Over expression of ALDH1A1 in myeloma cells led to increased mRNA and protein levels of NIMA-related kinase 2 (NEK2), whereas shRNA-mediated knock down of NEK2 decreased drug efflux pump activity and drug resistance. The activation of NEK2 in myeloma cells relied on the ALDH1A1-dependent generation of the retinoid X receptor α (RXRα) ligand, 9-cis retinoic acid (9CRA) - not the retinoic acid receptor α (RARα) ligand, all-trans retinoic acid (ATRA). These findings implicate the ALDH1A1-RXRα-NEK2 pathway in drug resistance and disease relapse in myeloma and suggest that specific inhibitors of ALDH1A1 are worthy of consideration for clinical development of new approaches to overcome drug resistance in myeloma.
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14
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Troppan K, Hofer S, Wenzl K, Lassnig M, Pursche B, Steinbauer E, Wiltgen M, Zulus B, Renner W, Beham-Schmid C, Deutsch A, Neumeister P. Frequent down regulation of the tumor suppressor gene a20 in multiple myeloma. PLoS One 2015; 10:e0123922. [PMID: 25856582 PMCID: PMC4391781 DOI: 10.1371/journal.pone.0123922] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/09/2015] [Indexed: 11/18/2022] Open
Abstract
Multiple myeloma (MM) is a malignant clonal expansion of plasma cells in the bone marrow and belongs to the mature B-cell neoplams. The pathogenesis of MM is associated with constitutive NF-κB activation. However, genetic alterations causing constitutive NF-κB activation are still incompletely understood. Since A20 (TNFAIP3) is a suppressor of the NF-κB pathway and is frequently inactivated in various lymphoid malignancies, we investigated the genetic and epigenetic properties of A20 in MM. In total, of 46 patient specimens analyzed, 3 single base pair exchanges, 2 synonymous mutations and one missense mutation were detected by direct sequencing. Gene copy number analysis revealed a reduced A20 gene copy number in 8 of 45 (17.7%) patients. Furthermore, immunohistochemical staining confirmed that A20 expression correlates with the reduction of A20 gene copy number. These data suggest that A20 contributes to tumor formation in a significant fraction of myeloma patients.
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Affiliation(s)
- Katharina Troppan
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Sybille Hofer
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Kerstin Wenzl
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Markus Lassnig
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Beata Pursche
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | | - Marco Wiltgen
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Barbara Zulus
- Division of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Wilfried Renner
- Division of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | | | - Alexander Deutsch
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Peter Neumeister
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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15
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Stella F, Pedrazzini E, Baialardo E, Fantl DB, Schutz N, Slavutsky I. Quantitative analysis of CKS1B mRNA expression and copy number gain in patients with plasma cell disorders. Blood Cells Mol Dis 2014; 53:110-7. [PMID: 24973170 DOI: 10.1016/j.bcmd.2014.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 05/19/2014] [Indexed: 12/28/2022]
Abstract
In this study, we have examined CKS1B gene expression and copy number in a total of 114- patients at diagnosis: 83 with multiple myeloma (MM) and 31 with monoclonal gammopathy of undetermined significance (MGUS). Results were correlated with cytogenetics, FISH and clinical characteristic. Significant CKS1B mRNA levels in MM compared to MGUS cases (p<0.048) were detected. In MM, the frequency of 1q21 (CKS1B) copy gain was significantly higher in cases with abnormal karyotype compared to patients with normal karyotype (p=0.021). Global analysis showed a positive correlation between CKS1B expression and 1q21 copy number (p<0.0001). No association between CKS1B mRNA expression and clinical parameters was found. However, a significantly higher level of β2 microglobulin in cases with 1q21 gains than those without (p=0.0094) was observed. Overall survival was shorter in cases with 1q21 gain compared to those with normal 1q21 region (p=0.0082). Our results suggest a role for CKS1B in the multiple step process of progression of MGUS to MM and show that CKS1B copy gain has a more significant prognostic value than its overexpression. This adverse impact on survival probably reflects the genetic instability associated to chromosome 1q alterations resulting in a more aggressive behavior of the disease.
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Affiliation(s)
- Flavia Stella
- Laboratorio de Genética de Neoplasias Linfoides, Instituto de Medicina Experimental, CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina.
| | - Estela Pedrazzini
- Laboratorio de Genética de Neoplasias Linfoides, Instituto de Medicina Experimental, CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina; Universidad Nacional del Noroeste de la Provincia de Buenos Aires (UNNOBA), Argentina
| | | | - Dorotea Beatriz Fantl
- Departamento de Clínica Médica, Sección Hematología, Hospital Italiano de Buenos Aires, Argentina
| | - Natalia Schutz
- Departamento de Clínica Médica, Sección Hematología, Hospital Italiano de Buenos Aires, Argentina
| | - Irma Slavutsky
- Laboratorio de Genética de Neoplasias Linfoides, Instituto de Medicina Experimental, CONICET-Academia Nacional de Medicina, Buenos Aires, Argentina
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16
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Walker BA, Wardell CP, Brioli A, Boyle E, Kaiser MF, Begum DB, Dahir NB, Johnson DC, Ross FM, Davies FE, Morgan GJ. Translocations at 8q24 juxtapose MYC with genes that harbor superenhancers resulting in overexpression and poor prognosis in myeloma patients. Blood Cancer J 2014; 4:e191. [PMID: 24632883 PMCID: PMC3972699 DOI: 10.1038/bcj.2014.13] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 02/06/2014] [Indexed: 02/06/2023] Open
Abstract
Secondary MYC translocations in myeloma have been shown to be important in the pathogenesis and progression of disease. Here, we have used a DNA capture and massively parallel sequencing approach to identify the partner chromosomes in 104 presentation myeloma samples. 8q24 breakpoints were identified in 21 (20%) samples with partner loci including IGH, IGK and IGL, which juxtapose the immunoglobulin (Ig) enhancers next to MYC in 8/23 samples. The remaining samples had partner loci including XBP1, FAM46C, CCND1 and KRAS, which are important in B-cell maturation or myeloma pathogenesis. Analysis of the region surrounding the breakpoints indicated the presence of superenhancers on the partner chromosomes and gene expression analysis showed increased expression of MYC in these samples. Patients with MYC translocations had a decreased progression-free and overall survival. We postulate that translocation breakpoints near MYC result in colocalization of the gene with superenhancers from loci, which are important in the development of the cell type in which they occur. In the case of myeloma these are the Ig loci and those important for plasma cell development and myeloma pathogenesis, resulting in increased expression of MYC and an aggressive disease phenotype.
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Affiliation(s)
- B A Walker
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - C P Wardell
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - A Brioli
- 1] Division of Molecular Pathology, The Institute of Cancer Research, London, UK [2] Istituto di Ematologia Seràgnoli, Università degli Studi di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - E Boyle
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - M F Kaiser
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - D B Begum
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - N B Dahir
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - D C Johnson
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
| | - F M Ross
- Wessex Regional Genetics Laboratory, Salisbury District Hospital, Salisbury, UK
| | - F E Davies
- Divisions of Molecular Pathology, Cancer Therapeutics and Clinical Sciences, The Institute of Cancer Research, London, UK
| | - G J Morgan
- Division of Molecular Pathology, The Institute of Cancer Research, London, UK
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17
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Paszekova H, Kryukov F, Kubiczkova L, Hajek R, Sevcikova S. High-risk multiple myeloma: different definitions, different outcomes? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 14:24-30. [PMID: 24225331 DOI: 10.1016/j.clml.2013.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/11/2013] [Accepted: 09/24/2013] [Indexed: 12/23/2022]
Abstract
Multiple myeloma (MM) is a clonal plasma cell malignancy. Although MM is still not completely curable, it can be maintained at the level of a long-term chronic condition. Irrespective of the treatment strategy, relapse is still a major problem for most patients. Approximately 10% to 15% of all MM patients relapse early and have poor prognosis and outcome. Currently, there are many ways of identifying these high-risk patients using cytogenetics or molecular biology. Despite these various approaches to definition of high risk patients, a clear definition of high-risk MM has not been widely accepted. In this review, we discuss and compare various approaches, and their strengths and weaknesses in early identification of high-risk MM patients.
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Affiliation(s)
- Helena Paszekova
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Fedor Kryukov
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Lenka Kubiczkova
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Clinical Hematology, University Hospital Brno, Czech Republic
| | - Roman Hajek
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Clinical Hematology, University Hospital Brno, Czech Republic
| | - Sabina Sevcikova
- Babak Myeloma Group, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Clinical Hematology, University Hospital Brno, Czech Republic.
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18
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Li Y, Wang X, Zheng H, Wang C, Minvielle S, Magrangeas F, Avet-Loiseau H, Shah PK, Zhang Y, Munshi NC, Li C. Classify hyperdiploidy status of multiple myeloma patients using gene expression profiles. PLoS One 2013; 8:e58809. [PMID: 23554930 PMCID: PMC3598955 DOI: 10.1371/journal.pone.0058809] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 02/07/2013] [Indexed: 01/01/2023] Open
Abstract
Multiple myeloma (MM) is a cancer of antibody-making plasma cells. It frequently harbors alterations in DNA and chromosome copy numbers, and can be divided into two major subtypes, hyperdiploid (HMM) and non-hyperdiploid multiple myeloma (NHMM). The two subtypes have different survival prognosis, possibly due to different but converging paths to oncogenesis. Existing methods for identifying the two subtypes are fluorescence in situ hybridization (FISH) and copy number microarrays, with increased cost and sample requirements. We hypothesize that chromosome alterations have their imprint in gene expression through dosage effect. Using five MM expression datasets that have HMM status measured by FISH and copy number microarrays, we have developed and validated a K-nearest-neighbor method to classify MM into HMM and NHMM based on gene expression profiles. Classification accuracy for test datasets ranges from 0.83 to 0.88. This classification will enable researchers to study differences and commonalities of the two MM subtypes in disease biology and prognosis using expression datasets without need for additional subtype measurements. Our study also supports the advantages of using cancer specific characteristics in feature design and pooling multiple rounds of classification results to improve accuracy. We provide R source code and processed datasets at www.ChengLiLab.org/software.
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Affiliation(s)
- Yingxiang Li
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
| | - Xujun Wang
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
| | - Haiyang Zheng
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
| | - Chengyang Wang
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
| | - Stéphane Minvielle
- Inserm UMR892, CNRS 6299, Université de Nantes, Centre Hospitalier Universitaire de Nantes, Unité Mixte de Genomique du Cancer, Nantes, France
| | - Florence Magrangeas
- Inserm UMR892, CNRS 6299, Université de Nantes, Centre Hospitalier Universitaire de Nantes, Unité Mixte de Genomique du Cancer, Nantes, France
| | - Hervé Avet-Loiseau
- Inserm UMR892, CNRS 6299, Université de Nantes, Centre Hospitalier Universitaire de Nantes, Unité Mixte de Genomique du Cancer, Nantes, France
| | - Parantu K. Shah
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Yong Zhang
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
| | - Nikhil C. Munshi
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, and Boston VA Healthcare System, Boston, Massachusetts, United States of America
| | - Cheng Li
- Department of Bioinformatics, School of Life Science and Technology, Tongji University, Shanghai, China
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
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19
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Uncovering the biology of multiple myeloma among African Americans: a comprehensive genomics approach. Blood 2013; 121:3147-52. [PMID: 23422747 DOI: 10.1182/blood-2012-07-443606] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Epidemiological data have suggested that African American (AA) persons are twice as likely to be diagnosed with multiple myeloma (MM) compared with European American (EA) persons. Here, we have analyzed a set of cytogenetic and genomic data derived from AA and EA MM patients. We have compared the frequency of IgH translocations in a series of data from 115 AA patients from 3 studies and 353 EA patients from the Eastern Cooperative Oncology Group (ECOG) studies E4A03 and E9487. We have also interrogated tumors from 45 AA and 196 EA MM patients for somatic copy number abnormalities associated with poor outcome. In addition, 35 AA and 178 EA patients were investigated for a transcriptional profile associated with high-risk disease. Overall, based on this cohort, genetic profiles were similar except for a significantly lower frequency of IgH translocations (40% vs 52%; P = .032) in AA patients. Frequency differences of somatic copy number aberrations were not significant after correction for multiple testing. There was also no significant difference in the frequency of high-risk disease based on gene expression profiling. Our study represents the first comprehensive comparisons of the frequency and distribution of molecular alterations in MM tumors between AA and EA patients. ECOG E4A03 is registered with ClinicalTrials.gov, number NCT00098475. ECOG E9487 is a companion validation set to the ECOG study E9486 and is registered with the National Institutes of Health, National Cancer Institute, Clinical Trials (PDQ), number EST-9486.
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20
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Hyperhaploid plasma cell myeloma. Cancer Genet 2012; 205:414-8. [PMID: 22868003 DOI: 10.1016/j.cancergen.2012.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 04/18/2012] [Accepted: 05/09/2012] [Indexed: 11/22/2022]
Abstract
Conventional cytogenetics shows chromosome abnormalities in one third of plasma cell myeloma (PCM) cases. These chromosome abnormalities can be used to divide PCM into two major aneuploidy groups: hyperdiploid PCM and non-hyperdiploid PCM. Hypodiploid PCM is associated with a poor prognosis relative to other ploidy groups. Hypodiploid karyotypes usually have a modal number of 40 or more. Near haploidy is a rare phenomenon in PCM. We present three cases of PCM with hyperhaploid karyotypes from our laboratory, and review three cases reported in the literature. All six cases had modal numbers ranging from 27 to 33. Two copies of chromosomes 3, 7, 9, 11, 15, 18 and 19 were present in all cases. Five of the six cases had two copies of chromosome 21 and four of the six cases had two copies of chromosome 5. The three patients studied at our laboratory had aggressive disease and a short survival but the small number of cases makes predicting outcome in this group difficult. The consistent pattern of cytogenetic abnormalities present in these cases suggests that hyperhaploidy may be a distinct cytogenetic entity in PCM.
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21
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Nagoshi H, Taki T, Hanamura I, Nitta M, Otsuki T, Nishida K, Okuda K, Sakamoto N, Kobayashi S, Yamamoto-Sugitani M, Tsutsumi Y, Kobayashi T, Matsumoto Y, Horiike S, Kuroda J, Taniwaki M. Frequent PVT1 rearrangement and novel chimeric genes PVT1-NBEA and PVT1-WWOX occur in multiple myeloma with 8q24 abnormality. Cancer Res 2012; 72:4954-62. [PMID: 22869583 DOI: 10.1158/0008-5472.can-12-0213] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Chromosome 8q24 rearrangements are occasionally found in multiple myeloma and are associated with tumor progression. The 8q24 rearrangements were detected by FISH in 12 of 54 patients with multiple myeloma (22.2%) and in 8 of 11 multiple myeloma cell lines (72.7%). The breakpoints of 8q24 in 10 patients with multiple myeloma and in all multiple myeloma cell lines were assigned to a 360 kb segment, which was divided into 4 regions: approximately 120 kb centromeric to MYC (5' side of MYC), the region centromerically adjacent to PVT1 (~ 170 kb region, including MYC, of 5' side of PVT1), the PVT1 region, and the telomeric region to PVT1. PVT1 rearrangements were most common and found in 7 of 12 patients (58.3%) and 5 of 8 cell lines (62.5%) with 8q24 abnormalities. A combination of spectral karyotyping (SKY), FISH, and oligonucleotide array identified several partner loci of PVT1 rearrangements, such as 4p16, 4q13, 13q13, 14q32, and 16q23-24. Two novel chimeric genes were identified: PVT1-NBEA in the AMU-MM1 cell line harboring t(8;13)(q24;q13) and PVT1-WWOX in RPMI8226 cell line harboring der(16)t(16;22)ins(16;8)(q23;q24). The PVT1-NBEA chimera in which PVT1 exon 1 was fused to NBEA exon 2 and the PVT1-WWOX in which PVT1 exon 1 was fused to WWOX exon 9 were associated with the expression of abnormal NBEA and WWOX lacking their N-terminus, respectively. These findings suggest that PVT1 rearrangements may represent a novel molecular paradigm underlying the pathology of 8q24 rearrangement-positive multiple myeloma.
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Affiliation(s)
- Hisao Nagoshi
- Department of Hematology and Oncology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
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22
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Fett-Conte AC, Carvalho-Salles AB, Vendrame CB, Pedrassa P, Freitas PC, Varella-Garcia M. New complex chromosome abnormalities in multiple myeloma associated with a poor prognosis: A case report. Leuk Res 2012; 36:e140-2. [DOI: 10.1016/j.leukres.2012.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 02/27/2012] [Accepted: 02/28/2012] [Indexed: 11/28/2022]
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23
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Durak BA, Akay OM, Sungar G, Bademci G, Aslan V, Caferler J, Ozdemir M, Cilingir O, Artan S, Gülbaş Z. Conventional and molecular cytogenetic analyses in Turkish patients with multiple myeloma. Turk J Haematol 2012; 29:135-42. [PMID: 24744644 PMCID: PMC3986951 DOI: 10.5152/tjh.2011.42] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 06/13/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Multiple myeloma (MM) is characterized by the accumulation and proliferation of malignant plasma cells, secreting monoclonal immunoglobulins and genetic abnormalities in MM have implications for disease progression and survival. In the present study, we investigated the frequency of chromosomal abnormalities (CA) in Turkish patients with MM, using interphase FISH and CC and evaluated the relationship between the rearrangements detected, prognosis and stage of disease. MATERIAL AND METHODS We performed conventional cytogenetic and FISH studies in 50 patients to detect chromosome anomalies associated with MM. FISH probes were used to detect 13q14, 13q34, 17p13 deletions, IGH rearrangements, and monosomy and/or trisomy of chromosomes 5, 9, and 15. RESULTS CC studies could be performed in 32 of 50 cases and five patients (15.6%) showed chromosomal aberrations while 27 (84.3%) had normal karyotypes. By FISH, eighteen percent (9/50) of cases were found to be normal for all parameters evaluated. Eighty-two percent (41/50) of the patients were positive for at least one abnormality. Chromosome 13 anomalies were detected in 54% (27/50) of cases. The second most common aberration observed is chromosome 15 aberrations (50%). CONCLUSION Median survival rate was shorter in patients with one of the abnormalities including chromosome 13 aberrations, IGH rearrangements or P53 deletions. Chromosome 15 aberrations were significantly higher in patients with stage III disease (p=0.02). We conclude that FISH studies should be performed in conjunction with conventional cytogenetic analysis for prognosis in multiple myeloma patients.
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Affiliation(s)
- Beyhan Aras Durak
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Olga Meltem Akay
- Eskisehir Osmangazi University, Medical Faculty, Department of Hematology, Eskisehir, Turkey
| | - Gülçin Sungar
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Güney Bademci
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Vahap Aslan
- Yunus Emre State Hospital, Department of Hematology, Eskisehir, Turkey
| | | | - Muhsin Ozdemir
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Oğuz Cilingir
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Sevilhan Artan
- Eskisehir Osmangazi University, Medical Faculty, Department of Medical Genetics, Eskisehir, Turkey
| | - Zafer Gülbaş
- Eskisehir Osmangazi University, Medical Faculty, Department of Hematology, Eskisehir, Turkey
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24
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López-Nieva P, Vaquero C, Fernández-Navarro P, González-Sánchez L, Villa-Morales M, Santos J, Esteller M, Fernández-Piqueras J. EPHA7, a new target gene for 6q deletion in T-cell lymphoblastic lymphomas. Carcinogenesis 2012; 33:452-8. [PMID: 22114070 DOI: 10.1093/carcin/bgr271] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Cryptic deletions at chromosome 6q are common cytogenetic abnormalities in T-cell lymphoblastic leukemia/lymphoma (T-LBL), but the target genes have not been formally identified. Our results build on detection of specific chromosomal losses in a mouse model of γ-radiation-induced T-LBLs and provide interesting clues for new putative susceptibility genes in a region orthologous to human 6q15-6q16.3. Among these, Epha7 emerges as a bona fide candidate tumor suppressor gene because it is inactivated in practically all the T-LBLs analyzed (100% in mouse and 95.23% in human). We provide evidence showing that Epha7 downregulation may occur, at least in part, by loss of heterozygosity (19.35% in mouse and 12.5% in human) or promoter hypermethylation (51.61% in mouse and 43.75% in human) or a combination of both mechanisms (12.90% in mouse and 6.25% in human). These results indicate that EPHA7 might be considered a new tumor suppressor gene for 6q deletions in T-LBLs. Notably, this gene is located in 6q16.1 proximal to GRIK2 and CASP8AP2, other candidate genes identified in this region. Thus, del6q seems to be a complex region where inactivation of multiple genes may cooperatively contribute to the onset of T-cell lymphomas.
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MESH Headings
- Animals
- Calcium-Binding Proteins/genetics
- Cell Line, Tumor
- Chromosome Deletion
- Chromosomes, Human, Pair 4
- Chromosomes, Human, Pair 6/genetics
- DNA Methylation
- Down-Regulation
- Female
- Genes, Tumor Suppressor
- Humans
- Jurkat Cells
- Leukemia, T-Cell/genetics
- Leukemia-Lymphoma, Adult T-Cell/genetics
- Loss of Heterozygosity
- Lymphoma, T-Cell/genetics
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Promoter Regions, Genetic
- Receptor, EphA7/genetics
- Receptors, Kainic Acid/genetics
- Sequence Deletion
- GluK2 Kainate Receptor
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Affiliation(s)
- Pilar López-Nieva
- Departmento Biología Celular e Inmunología, Centro de Biología Molecular Severo Ochoa, Consejo Superior de Investigaciones Científicas-Universidad Autónoma de Madrid, Nicolás Cabrera 1, 28049 Madrid, Spain
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25
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Gmidène A, Avet-Loiseau H, Sennana H, Ben Abdallah I, Khlif A, Meddeb B, Elloumi M, Saad A. Molecular cytogenetic aberrations in Tunisian patients with multiple myeloma identified by cIg-FISH in fixed bone marrow cells. Cytogenet Genome Res 2011; 136:44-9. [PMID: 22188899 DOI: 10.1159/000334878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2011] [Indexed: 01/18/2023] Open
Abstract
Cytogenetic studies in multiple myeloma (MM) are hampered by the hypo-proliferative nature of plasma cells. In order to circumvent this problem, we have used a combination of immunolabeling of cytoplasmic Ig light chains (λ or κ) and FISH (cIg-FISH), which allowed a comprehensive detection of the most common and/or recurrent molecular cytogenetic aberrations on fixed bone marrow cells of 70 Tunisian patients. Translocations involving the chromosome 14q32 region were observed in 32 cases (45.7%), including 18 cases with a t(11;14), 8 cases with a t(4;14), and 2 cases with a t(14;16). Deletions of the 13q14 region (D13S319/RB1) were detected in 18.6%, and deletions of the 17p13 region (TP53) in 5.7% of the cases, respectively. Of all patients with a D13S319/RB1 deletion, 61.5% also carried a 14q32 translocation, whereas TP53 deletions were associated with a t(11;14) in 2 cases (50%) and a D13S319 deletion in 1 case (25%). Our results suggest that there is a correlation between the presence of 14q32 translocations and chromosome 13q14 deletions in MM patients and that cIg-FISH is more sensitive as compared to conventional karyotyping in detecting molecular cytogenetic abnormalities in this disease.
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Affiliation(s)
- A Gmidène
- Department of Cytogenetics and Reproductive Biology, Farhat Hached University Hospital, Sousse, Tunisia.
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26
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Abstract
Plasmablastic lymphoma (PBL) is an aggressive lymphoma characterized by a terminally differentiated B-cell phenotype that usually occurs in the immunocompromised or elderly patients. Although the clinical and pathologic characteristics of these tumors have been defined, the genetic alterations involved in their pathogenesis are not well known. In this study, we have investigated the chromosomal alterations of MYC, BCL2, BCL6, MALT1, PAX5, and IGH loci using fluorescence in situ hybridization in 42 PBL and 3 extracavitary primary effusion lymphomas. MYC rearrangements were identified in 20 of 41 (49%) PBL and the immunoglobulin (IG) genes were the partners in most tumors. MYC rearrangements were more common in Epstein-Barr virus (EBV)-positive (14 of 19, 74%) than EBV-negative (9 of 21, 43%) tumors (P<0.05). No rearrangements of BCL2, BCL6, MALT1, or PAX5 were detected in any PBL but gains of these loci were observed in 31% to 41% of the cases examined. Twelve of the 40 PBL in which 3 or more loci could be investigated had multiple simultaneous gains in 3 or more loci. No differences in the survival of the patients according to MYC were observed but the 4 patients with the longest survival (>50 mo) had no or low number of gains (<3). No rearrangements of any of these loci were seen in the primary effusion lymphomas. In conclusion, PBL are genetically characterized by frequent IG/MYC translocations and gains in multiple chromosomal loci. The oncogenic activation of MYC in these lymphomas may be an important pathogenetic element associated with EBV infection.
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27
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Near-tetraploidy clone can evolve from a hyperdiploidy clone and cause resistance to lenalidomide and bortezomib in a multiple myeloma patient. Leuk Res 2010; 34:954-7. [DOI: 10.1016/j.leukres.2010.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 12/12/2009] [Accepted: 01/11/2010] [Indexed: 11/16/2022]
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28
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Lennon PA, Zhuang Y, Pierson D, Zhang X, Williams C, Perez C, Lin P. Bacterial artificial chromosome array-based comparative genomic hybridization using paired formalin-fixed, paraffin-embedded and fresh frozen tissue specimens in multiple myeloma. Cancer 2009; 115:345-54. [PMID: 19109814 DOI: 10.1002/cncr.24021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multiple myeloma (MM) is a neoplasm of malignant plasma cells that often harbors many chromosomal aberrations. Currently, fresh frozen tissues (FT) are considered the most reliable for molecular genetic analysis; however, formalin-fixed, paraffin-embedded (FFPE) tissues are easily retrievable. Compared with conventional cytogenetics, bacterial artificial chromosome (BAC) array-comparative genomic hybridization (CGH) allows more sensitive detection of chromosomal abnormalities. METHODS The authors analyzed 7 paired FT and FFPE samples of bone marrow aspirate materials obtained from patients with MM in parallel to determine the efficacy of BAC array-CGH using FFPE. RESULTS Thirty-four aberrations were identified, including 29 that were observed in both sample types, yielding 85% concordance. Nonrandom anomalies, including gains on 7q, 9q, 15q, and 19p and losses on 8p and 13q, were observed in paired samples from at least 2 patients. To verify these results, fluorescence in situ hybridization (FISH) was performed using probes specific for 7q and 15q, and gains were observed in the 4 samples that were examined. Furthermore, 1 of 3 samples from patients who had monoclonal gammopathy of undetermined significance that were tested also carried gain on 7q, suggesting that this aberration may be an early transforming event. CONCLUSIONS The current results indicated that BAC array-CGH can be effective using FFPE samples and is a sensitive method for the identification of nonrandom chromosomal aberrations in MM.
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Affiliation(s)
- Patrick A Lennon
- School of Health Sciences, Department of Hematopathology, the University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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29
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Lee JW, Lee JK, Hong YJ, Hong SI, Chang YH. Correlation of Chromosomal Aberrations with Prognostic Markers in Multiple Myeloma Patients-A Single Institution Study. Ann Lab Med 2008; 28:413-8. [DOI: 10.3343/kjlm.2008.28.6.413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Ji Won Lee
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Jin Kyung Lee
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Young Joon Hong
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Seok-Il Hong
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
| | - Yoon Hwan Chang
- Department of Laboratory Medicine, Korea Cancer Center Hospital, Seoul, Korea
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30
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Ozet A, Güran S, Beksac M. Familial multiple myeloma associated with disorders of chronic inflammation: first report from Turkey. ACTA ACUST UNITED AC 2008; 8:246-8. [PMID: 18765313 DOI: 10.3816/clm.2008.n.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Multiple myeloma (MM) is a malignancy arising from mature plasma cells in the bone marrow and usually presents with bone destruction, hypercalcemia, anemia, renal damage, and increased susceptibility to infection. The etiology of MM is unknown, with no established lifestyle, occupational, or environmental risk factors. Because MM is an uncommon disease, etiologic assessments can be difficult. It has been reported to be in association with sarcoidosis, and in a few cases, rheumatoid arthritis. Familial type of MM with an autosomal dominant heredity pattern has also been reported. The genetic loci affected in these cases are still unknown. Herein we present a family with 3 affected cases in an autosomal dominant inheritance pattern. The first case was a man diagnosed to have immunoglobulin (Ig)A-type myeloma at the age of 50. The history revealed 2 more cases in the family: an uncle diagnosed to have unsecretory-type myeloma at the age of 76 and a cousin (the daughter of the affected uncle) who was diagnosed at the age of 48 years to have IgG-type myeloma and did not respond to therapy. This patient also had a history of sarcoidosis preceding the diagnosis of myeloma. All other affected family members had been treated for dental-oral infection (including chronic gingivitis) for 3 and 4 years before the diagnosis of myeloma. Karyotype analysis revealed pseudohypodiploidy and deletion of chromosome 13q in only the patient with coexisting sarcoidosis. To our knowledge, this is the first report on familial myeloma from Turkey. This family enhances the role of hereditary factors and chronic inflammation in the etiology of MM.
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Affiliation(s)
- Ahmet Ozet
- Department of Medical Oncology, Gülhane Military Medical Academy, Ankara, Turkey
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