Proliferative activity of plasma cells is the most relevant prognostic factor in elderly multiple myeloma patients

Impact of acquired del(17p) in multiple myeloma

The high-risk abnormality del(17p) can be detected by fluorescence in situ hybridization on malignant plasma cells (PCs) and has an adverse prognostic impact in patients with multiple myeloma (MM). Patients with del(17p) have reduced overall survival (OS). Patients who acquire del(17p) later during the disease course are not well described. The disease characteristics at diagnosis predicting for acquired del(17p) and its overall impact on patient survival is not known. We compared 76 patients with MM who were negative for del(17p) at diagnosis and acquired it later with 152 control MM patients who did not acquire del(17p) at a comparable time point. Patients acquired del(17p) at a median of 35.6 months (range, 4.6-116.1 months) from diagnosis of MM after a median of 2 lines of therapy (range, 1-10 lines of therapy). When compared with controls, patients with acquired del(17p) had shorter median progression-free survival (PFS) (30.1 vs 23.0 months; P = .032) and OS (106.1 vs 68.2 months; P < .001) from diagnosis. After the detection of del(17p), the median PFS was 5.4 months and the median OS was 18.1 months. High lactate dehydrogenase level (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.11-12.24) and presence of t(4;14) (OR, 2.66; 95% CI, 1.09-6.48) or any high-risk translocation (OR, 2.23; 95% CI, 1.00-4.95) at diagnosis predicted acquisition of del(17p). High PC proliferative rate predicted shorter OS from detection of del(17p) (hazard ratio, 2.28; 95% CI, 1.31-3.96; P = .004). Our study shows that acquisition of del(17p) is an important molecular event associated with reduction in OS in MM. Certain baseline factors may predict acquisition of del(17p). This needs validation in prospective data sets.

Correlations of DKK1 with pathogenesis and prognosis of human multiple myeloma

OBJECTIVE

Human multiple myeloma (MM) is a kind of common tumor in middle-aged and elderly people, in which the osteolytic lesion is formed mainly through inhibiting osteoblast (OB) differentiation and promoting osteoclast (OC) differentiation. Dickkopf-1 (DKK1) is a soluble Wnt inhibitor, which has an important correlation with the pathogenesis of human MM. Therefore, the correlations of DKK1 with pathogenesis and prognosis of human MM were investigated in this study.

METHODS

The DKK1 expression in tissues and serum of myeloma patients was detected via immunohistochemistry and enzyme-linked immunosorbent assay (ELISA). Correlation between DKK1 expression and survival time of patients was analyzed via Kaplan-Meier analysis. To further study the mechanism of DKK1 expression in pathogenesis and prognosis of human MM, MM cells were treated with DKK1 neutralizing antibody (BHQ880) or transfected with DKK1-small-interfering ribonucleic acid (siRNA) to study its effects on OB differentiation, osteocalcin level, β-catenin and interleukin-6 (IL-6) secretion. Moreover, the effect of DKK1-siRNA transfection on the activity of U266 cells was detected via methyl thiazolyl tetrazolium (MTT) assay.

RESULTS

The DKK1 expression in tissues and serum of myeloma patients was significantly higher than that in control group (p< 0.01). In terms of survival time, the median survival time (45 months) in patients with low DKK1 expression was significantly longer than that in patients with high DKK1 expression (only 22 months). The DKK1 neutralizing antibody (BHQ880) and DKK1-siRNA significantly reduced the DKK1 level in MM cells, promoted the OB differentiation, increased the osteocalcin deposition, promoted the β-catenin expression and decreased the IL-6 expression and β-catenin phosphorylation. DKK1-siRNA could also reduce the proliferative activity of MM cells.

CONCLUSION

DKK1 is closely related to the pathogenesis and prognosis of human MM, which might be a potential biomarker for the diagnosis of MM.

Clinical Relevance of Multicolour Flow Cytometry in Plasma Cell Disorders

Multicolor flow cytometric (MFC) immunophenotyping is one of the basic test that is needed in the evaluation of hematolymphoid malignancies. Previously, there has been some reluctance in the use of MFC in plasma cell disorders (PCD). It was mainly due tolack of standardization, inadequate experience and detection of the lower number of plasma cells by MFC as compared to morphology. However, MFC has gone through many technological advancements in the last few years and a wide variety of reagents are now commercially available which worldwide allowed the establishment of standardized sensitive MFC-based immunophenotypic assay for PCD. Various studies have proven that MFC has a high clinical relevance in the diagnosis and risk stratification of multiple myeloma, its precursor conditions and other PCDs. Moreover, recent studies have shown that MFC is a highly sensitive and reliable technique for the monitoring of clinical response in the era of novel therapies. In this review, we have discussed the various applications of MFC in the management of PCD and their clinical relevance.

AYA-Myeloma: Real-World, Single-Center Experience Over Last 5 Years

INTRODUCTION

Multiple myeloma (MM) is considered as a disease of the old with the reported median age of 60-70 years. The disease occurred a decade earlier in the Indian subcontinent. The literature on MM in adolescents and young adult (AYA) is limited. We studied the disease characteristics and outcomes of the AYA-MM in the real-world setting.

PATIENTS AND METHODS

It is a retrospective single-center study conducted at a tertiary care center from North India. Records of all consecutive patients with AYA-MM (15-39 years of age) who were managed from January 1, 2010, to December 30, 2015, were reviewed. Survival was assessed from the date of start of treatment to the last follow-up date or death due to any cause.

RESULTS

A total of 415 patients managed for MM were included in the study. The frequency of the AYA-MM was 9.6% (40/415) of whom 5 patients were younger than 30 years. There was male preponderance with a median age of the patients being 38 years. The main presenting features were bone pain (55%), fatigue (45%), extramedullary plasmacytomas (20%), and infections (12%) and referral from the peripheral hospital as renal dysfunction (58%). On the evaluation of patients, hypercalcemia, renal impairment, anemia, and lytic lesions were seen in 24.32%, 30%, 52.5%, and 59.25% of patients, respectively. The majority had the high-risk disease (International Staging System [ISS]-III: 75%). Only 22.5% patients were transplanted. The 3-year median overall survival of the study population was 80.21%.

CONCLUSION

AYA-MM patients have a higher prevalence of extramedullary disease and high-risk disease.

Cyclin D type does not influence cell cycle response to DNA damage caused by ionizing radiation in multiple myeloma tumours

Multiple myeloma (MM) is characterized by over-expression of cyclin D1 (CCND1) or D2 (CCND2), which control G1 phase cell-cycle progression. Proteolytic degradation of CCND1 (but not CCND2), resulting in G1 arrest, is reported in non-MM cells post-DNA damage, affecting DNA repair and survival. We examined the effect of ionizing radiation (IR) on D-cyclin levels and cell-cycle kinetics of MM cells, exploring differences based on D-cyclin expression. We showed that CCND1 is downregulated, whereas CCND2 is not, following IR. This did not lead to hypo-phosphorylation of retinoblastoma protein or G1 arrest. Both CCND1- and CCND2-expressing MM cells arrested in S/G2/M, and did not differ in other cell-cycle proteins or sensitivity to IR. When treated with a CDK4/6 inhibitor, both CCND1 and CCND2 MM cells arrested in G1 and therefore are subject to physiological regulation at this checkpoint. Immunoprecipitation showed that, despite CCND1 degradation following IR, sufficient protein remains bound to CDK4/6 to prevent G1 arrest. Aberrant expression of CCND1 driven from the IGH promoter in t(11;14) MM cells maintains progression through G1 to arrest in S/G2/M. Differential expression of D-cyclin does not appear to affect cell-cycle response to IR, and is unlikely to underlie differential sensitivity to DNA damage.

Immunophenotypic features by multiparameter flow cytometry can help distinguish low grade B-cell lymphomas with plasmacytic differentiation from plasma cell proliferative disorders with an unrelated clonal B-cell process

Highly sensitive flow cytometry studies may incidentally identify B cell clones when used to assess plasma cell clonality in bone marrows. Clinical history, which can help differentiate related clones (low grade B cell lymphoma with plasmacytic differentiation/LBCL-PD) from unrelated ones (plasma cell proliferative disorder (PCPD) with an unrelated B cell clone), is often unavailable in referred specimens. We sought to identify morphologic or phenotypic features that would help predict the significance of these clones in the absence of history. We included only cases with identical light chain B and plasma cell clones, as determined by 6-color flow cytometry with additional DNA ploidy analysis, in which the relationship between clones could be established by review of medical records. There were 26 cases; 18 were related (14 were Waldenstrom macroglobulinemia) and eight were unrelated (seven multiple myeloma). Features seen exclusively in LBCL-PD include CD19+/CD45+ clonal plasma cell phenotype (66·7%, P = 0·0022) and morphologic features such as paratrabecular bone marrow involvement, increased mast cells, and plasma cells surrounding B-cell nodules. Aneuploidy was identified exclusively in PCPD cases (75%, P = 0·000028). We conclude that CD19+/CD45+ clonal plasma cell phenotype and aneuploidy are useful in distinguishing related clones (LBCL-PD) from unrelated clones (PCPD).

Multiparameter flow cytometry evaluation of plasma cell DNA content and proliferation in 595 transplant-eligible patients with myeloma included in the Spanish GEM2000 and GEM2005<65y trials

The incorporation of high-dose therapy/autologous stem cell transplantation (HDT/ASCT) and novel agents has significantly improved survival in patients with multiple myeloma (MM), but whether this improvement also benefits patients harboring poor prognostic features, such as nonhyperdiploid MM (NH-MM) and a high proliferation index, remains largely unknown. We analyzed the DNA content and proliferation index of bone marrow plasma cells (PCs) by multiparameter flow cytometry in 595 newly diagnosed transplant-eligible patients with MM included in two consecutive PETHEMA/GEM trials: GEM2000 [VBMCP/VBAD (vincristine, carmustine, melphalan, cyclophosphamide, prednisone/vincristine, bischloroethylnitrosourea, adriamycin, and dexamethasone) followed by HDT/ASCT; n = 319] and GEM2005<65y (randomized induction with VBMCP/VBAD/bortezomib or thalidomide/dexamethasone or bortezomib/thalidomide/dexamethasone followed by HDT/ASCT; n = 276). Of the 595 patients, 295 were classified as NH-MM (49.6%) and 336 (56.5%) as high-proliferative MM (≥1% PCs in S-phase). Detection of NH-MM DNA content and ≥1% PCs in S-phase were of independent prognostic value for overall survival. Treatment with bortezomib-based regimens abrogated the inferior overall survival of patients with ≥1% PCs in S-phase but not of patients with NH-MM. Finally, a comparative analysis of PC proliferation index at diagnosis versus disease progression showed a twofold increase at relapse in 44 of 52 patients (85%) analyzed at both time points. NH-MM and a high proliferation index assessed by multiparameter flow cytometry remain as independent prognostic factors in MM, but the latter may be overcome by incorporating novel agents in the HDT/ASCT setting.

Inhibition of cell cycle progression by dual phosphatidylinositol-3-kinase and mTOR blockade in cyclin D2 positive multiple myeloma bearing IgH translocations

Multiple myeloma (MM) is a clinically and genetically heterogenous cancer where tumour cells have dysregulated expression of a D-type cyclin, often in association with a recurrent IgH translocation. Patients whose tumour cells express cyclin D2, with the translocation t(4;14) or t(14;16), generally have more proliferative disease and inferior outcomes. The phosphatidylinositol-3-kinase (PI3K) pathway is a major regulator of D-type cyclin expression and cell cycle entry. We evaluated the effect of PI3K pathway blockade on cell cycle behaviour in MM cells, investigating differences between cyclin D2- and cyclin D1-expressing tumours. MM cell lines and primary bone marrow CD138⁺ MM cells were exposed to the pan-PI3K/mTOR inhibitor, PI-103, and assessed for cell cycle profiles, [³H]-thymidine uptake and cell cycle proteins. We report, in both cell lines and primary MM cells, that PI-103 induced cell cycle arrest with downregulation of cyclin D2 and CDK4/6 in MM cells expressing cyclin D2 via t(4;14) or t(14;16) translocations. Cells expressing cyclin D1 via t(11;14) were insensitive to PI-103, despite exhibiting inhibition of downstream signalling targets. In primary MM cells, PI-103 enhanced the anti-proliferative effects of anti-MM agents. Treatment paradigms including blockade of the PI3K/mTOR pathway should be targeted at patients with IgH translocations associated with cyclin D2 overexpression.

Outcome according to cytogenetic abnormalities and DNA ploidy in myeloma patients receiving short induction with weekly bortezomib followed by maintenance

Cytogenetic abnormalities (CAs) such as t(4;14), t(14;16) or del(17p), and nonhyperdiploidy are associated with poor prognosis in multiple myeloma. We evaluated the influence of CAs by FISH and DNA ploidy by flow cytometry on response and survival in 232 elderly, newly diagnosed multiple myeloma patients receiving an induction with weekly bortezomib followed by maintenance therapy with bortezomib-based combinations. Response was similar in the high-risk and standard-risk CA groups, both after induction (21% vs 27% complete responses [CRs]) and maintenance (39% vs 45% CR). However, high-risk patients showed shorter progression-free survival (PFS) than standard-risk patients, both from the first (24 vs 33 months; P = .04) and second randomization (17 vs 27 months; P = .01). This also translated into shorter overall survival (OS) for high-risk patients (3-year OS: 55% vs 77%; P = .001). This adverse prognosis applied to either t(4;14) or del(17p). Concerning DNA ploidy, hyperdiploid patients showed longer OS than nonhyperdiploid patients (77% vs 63% at 3 years; P = .04), and this was more evident in patients treated with bortezomib, thalidomide, and prednisone (77% vs 53% at 3 years; P = .02). The present schema does not overcome the negative prognosis of high-risk CAs and nonhyperdiploidy. This trial was registered with www.ClinicalTrials.gov as NCT00443235.

Consensus recommendations for risk stratification in multiple myeloma: report of the International Myeloma Workshop Consensus Panel 2

A panel of members of the 2009 International Myeloma Workshop developed guidelines for risk stratification in multiple myeloma. The purpose of risk stratification is not to decide time of therapy but to prognosticate. There is general consensus that risk stratification is applicable to newly diagnosed patients; however, some genetic abnormalities characteristic of poor outcome at diagnosis may suggest poor outcome if only detected at the time of relapse. Thus, in good-risk patients, it is necessary to evaluate for high-risk features at relapse. Although detection of any cytogenetic abnormality is considered to suggest higher-risk disease, the specific abnormalities considered as poor risk are cytogenetically detected chromosomal 13 or 13q deletion, t(4;14) and del17p, and detection by fluorescence in situ hybridization of t(4;14), t(14;16), and del17p. Detection of 13q deletion by fluorescence in situ hybridization only, in absence of other abnormalities, is not considered a high-risk feature. High serum β(2)-microglobulin level and International Staging System stages II and III, incorporating high β(2)-microglobulin and low albumin, are considered to predict higher risk disease. There was a consensus that the high-risk features will change in the future, with introduction of other new agents or possibly new combinations.

Risk stratification in the era of novel therapies

Multiple myeloma (MM) is an heterogeneous disease and this concept, together with the recent discovery of new drugs with novel mechanisms of action, will lead to the design of individualized treatments. The term "high-risk MM" includes those patients with at least one of the following features: deletion of 17p or t(4;14) or t(14;16), detected by fluorescence in situ hybridization analysis; deletion of 13q detected by conventional cytogenetics; or hypodiploidy or complex karyotype. In addition, patients with high proliferative activity of plasma cells (> or = 3%) measured by the PC labeling index or S-phase by flow cytometry as well as those with a poor response to induction therapy are also high risk. The definition of high-risk MM has been based on patients treated with conventional drugs with or without autologous transplant. However, current data suggest that novel agents can overcome the initial adverse prognosis of deletion 13q and t(4;14) but probably not that of 17p deletion, at least when using immunomodulatory drugs. Nevertheless, the number of patients analyzed is rather limited and, more important, time to progression is only available in a small number of studies. On the basis of these data, it is probably premature to mandate specific therapies on the basis of cytogenetic abnormalities. Moreover, it is possible that the more intensive therapies selected for high-risk patients may be of even greater benefit to standard-risk cases. Accordingly, at present, although we discourage treatment of high-risk patients with conventional schedules, we recommend to include them in large cooperative trials based on novel agents and performing a comprehensive genetic analysis up-front, so that the patients benefiting most from each treatment can subsequently be identified.

Molecular and cellular effects of multi-targeted cyclin-dependent kinase inhibition in myeloma: biological and clinical implications

Cell cycle regulators, such as cyclin-dependent kinases (CDKs), are appealing targets for multiple myeloma (MM) therapy given the increased proliferative rates of tumour cells in advanced versus early stages of MM. We hypothesized that a multi-targeted CDK inhibitor with a different spectrum of activity compared to existing CDK inhibitors could trigger distinct molecular sequelae with therapeutic implications for MM. We therefore studied the small molecule heterocyclic compound NVP-LCQ195/AT9311 (LCQ195), which inhibits CDK1, CDK2 and CDK5, as well as CDK3 and CDK9. LCQ195 induced cell cycle arrest and eventual apoptotic cell death of MM cells, even at sub-μmol/l concentrations, spared non-malignant cells, and overcame the protection conferred to MM cells by stroma or cytokines of the bone marrow milieu. In MM cells, LCQ195 triggered decreased amplitude of transcriptional signatures associated with oncogenesis, drug resistance and stem cell renewal, including signatures of activation of key transcription factors for MM cells e.g. myc, HIF-1α, IRF4. Bortezomib-treated MM patients whose tumours had high baseline expression of genes suppressed by LCQ195 had significantly shorter progression-free and overall survival than those with low levels of these transcripts in their MM cells. These observations provide insight into the biological relevance of multi-targeted CDK inhibition in MM.

Chromatin-bound PCNA as S-phase marker in mononuclear blood cells of patients with acute lymphoblastic leukaemia or multiple myeloma

OBJECTIVES

Proliferating cell nuclear antigen (PCNA) has often been used as a marker to aid assessment of tumour growth fraction. This paper addresses the question of whether it can be used as an S-phase marker, when the non-chromatin-bound form of the protein is removed by pepsin treatment.

MATERIALS AND METHODS

Cytofluorometric measurements were carried out after immunofluorescence staining of PCNA and counterstaining of DNA. S-phase fraction was determined with the help of windows on PCNA versus DNA scattergrams, or mathematically from DNA histograms.

RESULTS

S-phase fractions obtained using the two methods correlated well, but did not always agree, exact discrepancies depending on the mathematical model used for histogram analysis.

CONCLUSIONS

Determination of S-phase fractions with the help of PCNA immunofluorescence staining is possible, and probably more reliable than calculation of S-fractions from DNA histograms. It thus offers an alternative to assays involving BrdU labelling in vivo.

Utility of flow cytometry immunophenotyping in multiple myeloma and other clonal plasma cell-related disorders

In recent years, multiparameter flow cytometry (MFC) immunophenotyping has become mandatory in the clinical management of hematological malignancies, both for diagnostic and monitoring purposes. Multiple myeloma (MM) and other clonal plasma cell-related (PC) disorders should be no exception to this paradigm, but incorporation of immunophenotypic studies in the management of patients with PC disorders is still far from being routinely established in many diagnostic flow cytometry laboratories. For clonal PC disorders, MFC is of clear and established clinical relevance in: (1) the differential diagnosis between MM and other PC-related disorders; (2) the identification of high-risk MGUS and smoldering MM; (3) minimal residual disease investigation after therapy; additionally it may also be useful for (4) the definition of prognosis-associated antigenic profiles; and (5) the identification of new therapeutic targets. In this article, we review the clinical value of MFC in the study of PC disorders, with specific emphasis in those areas where consensus exists on the need to incorporate MFC into routine evaluation of MM and other clonal PC-related disorders.

How best to use new therapies in multiple myeloma

Advances in the molecular understanding of myeloma have led to the development of novel agents such as immunomodulatory drugs (IMiDs) and proteasome inhibitors (bortezomib). When used alone, these agents have significant activity against myeloma and responses increase significantly when they are combined with additional agents including glucocorticosteroids and chemotherapeutic agents such as alkylators. There is a drive to use these novel agents in patients with newly diagnosed myeloma, where they lead to impressive response rates with increasing duration of responses. In addition, novel agents are now the mainstays of therapy for relapsed disease. In the following paper, we summarize the key observations from recent completed and ongoing studies that determined the effect of these novel therapies both in the setting of newly diagnosed myeloma and for relapsed disease. We also discuss our approach to the use of these agents in specific myeloma settings.

Importance of achieving a complete response in multiple myeloma, and the impact of novel agents

The goal of treatment for multiple myeloma (MM) is to improve patients' long-term outcomes. One important factor that has been associated with prolonged progression-free and overall survival is the quality of response to treatment, particularly achievement of a complete response (CR). There is extensive evidence from clinical studies in the transplant setting in first-line MM demonstrating that CR or maximal response post-transplant is significantly associated with prolonged progression-free and overall survival, with some studies demonstrating a similar association with postinduction response. Supportive evidence is also available from studies in the nontransplant and relapsed settings. With the introduction of bortezomib, thalidomide, and lenalidomide, higher rates of CR are being achieved in both first-line and relapsed MM compared with previous chemotherapeutic approaches, thereby potentially improving long-term outcomes. While standard CR by established response criteria has been shown to have differential prognostic impact compared with lesser responses, increasingly sensitive analytic techniques are now being explored to define more stringent degrees of CR or elimination of minimal residual disease (MRD), including multiparameter flow cytometry and polymerase chain reaction. Demonstrating eradication of MRD by these techniques has already been shown to predict for improved outcomes. Here, we review the prognostic significance of achieving CR in MM and highlight the importance of CR as an increasingly realizable goal at all stages of treatment. We discuss clinical management issues and provide recommendations relevant to practicing oncologists, such as the routine use of sensitive techniques for assessment of disease status to inform evidence-based decisions on optimal patient management.

Definitive diagnosis of multiple myeloma from rib specimens resected at thoracotomy in a patient with lung cancer

A 52-year-old man noted large amounts of bloody sputum and visited our hospital. Chest X-ray showed a mass shadow in the right upper lung field. He was diagnosed with squamous cell carcinoma (SCC). Although he was not aware of symptoms other than the bloody sputum, his blood chemistry showed a high total serum protein level of 10.6 g/dl. Further analysis of serum immunoglobulin revealed a markedly high immunoglobulin G (IgG) level, but an abnormally low level of immunoglobulin A (IgA) and immunoglobulin M (IgM). Serum immunoelectrophoresis detected IgG-lambda monoclonal protein; therefore, we suspected the coexistence of multiple myeloma, amyloidosis, benign macroglobulinemia, or benign monoclonal gammopathy. Since the patient continued to expectorate large amounts of bloody sputum every day, and his anemia progressed, right upper lobectomy and lymph node dissection were performed on a semi-emergent basis without preoperative bone marrow examination. On thoracotomy at the level of the fifth intercostal space, the fifth and sixth ribs were partially resected posteriorly, and the resected ribs were submitted for pathological examination. The postoperative pathological diagnosis was SCC of the lung (p-T2N0M0, stage IB). Pathological examination of the ribs revealed IgG-lambda myeloma. Herein, we report a patient with lung cancer in whom multiple myeloma was definitively diagnosed from rib specimens resected at thoracotomy.

Relevant prognostic features of multiple myeloma and the new International Staging System

The new International Staging System should be reported in all future studies of multiple myeloma. However, the system fails to account for recent research findings pertaining to mechanisms of disease progression. This review describes development of the International Staging System and details prognostic factors that may further our understanding of the biology of multiple myeloma.

Age 40 years and under does not confer superior prognosis in patients with multiple myeloma undergoing upfront autologous stem cell transmplant

Multiple myeloma (MM) rarely occurs in patients 40 years of age and younger. This young age has been reported to correlate with improved survival in patients with MM. The objective of this study is to describe presenting features and outcomes of patients < or =40 years of age with MM who undergo autologous stem cell transplantation (ASCT) as first-line treatment, and compare overall survival (OS) and progression free survival (PFS) to patients aged 41-65 years. We performed a retrospective institutional review of all patients < or =40 years of age and 41-65 years of age at the time of diagnosis of MM who had undergone upfront ASCT from January 1, 1990, to July 31, 2007. Thirty-eight patients < or =40 years of age and 608 patients aged 41-65 were identified. There was a high rate of plasma cell leukemia (PCL) in young patients at 11% compared to the reported rate of 2%-4%. At diagnosis, there was an increased rate of renal failure in the young cohort compared to patients aged 41-65 years at 25% versus 16% and Bence Jones proteinuria at 81% versus 51%. The rate of complete or partial response was similar between the groups at 79% and 83% in the young and older cohorts, respectively. Median PFS post-ASCT was 22.0 months (95% confidence interval [CI]: 16.1, 28.0), versus 26.9 months (95% CI: 24.0, 29.8) for patients aged 41-65 years (P = .66). Median OS from date of ASCT was also similar to those over 40 years: 68.1 months (95% CI: 39.0, 97.2) versus 80.7 months (95% CI: 68.1, 93.4); P = .90. Treatment-related mortality (TRM) was low at 2.6% and 2.3% in the young and older cohorts, respectively. Despite previous reports that young age is a positive prognostic marker, our study found OS post-ASCT is equivalent to those aged 41-65 years. This study emphasizes the importance of developing strategies to better the outcomes of young patients with MM.

Functional regulation of D-type cyclins by insulin-like growth factor-I and serum in multiple myeloma cells

D-type cyclin genes are universally dysregulated in multiple myeloma (MM), but the functional consequences are unclear as D-type cyclin gene expression does not correlate with proliferation or disease progression. We examined the protein expression and regulation of D-type cyclins and other cell cycle regulators in human myeloma cell lines and primary CD138(+) plasma cells (PCs). Cyclin D1, cyclin D2, cyclin dependent kinase (CDK) 4, CDK6, p27(Kip1) p18(INK4C) and retinoblastoma protein (pRb) were absent in normal PCs, heterogeneously expressed in primary MM cells and positively correlated with disease activity/progression. Cyclins D1 and D2 complexed with both CDK4 and CDK6, suggesting that both phosphorylate pRb in MM. Furthermore, cyclin D2 expressed via either t(14;16) or t(4;14) IgH translocations was functionally upregulated by fetal calf serum or insulin-like growth factor-I, leading to pRb phosphorylation and cell cycle entry/progression, and in some cases inversely correlated with p27(Kip1). However, pRb phosphorylation and cell cycle progression mediated by cyclin D1 expressed via t(11;14) was less dependent on exogenous stimuli. These data suggest that the presence or absence of specific IgH translocations underlying aberrant D-type cyclin expression may influence their response to mitogens in the bone marrow microenvironment. We showed for the first time that D-type cyclins are functionally regulated in MM, differentially responsive to exogenous growth factors and upregulated with disease progression.

Prognostic factors and staging in multiple myeloma

The field of multiple myeloma prognostication is replete with studies that have shown the value of independent predictors in determining clinical outcome. It is clear that host factors and factors intrinsic to the cells are the ultimate determinants of prognosis. In the immediate period after diagnosis, those factors related to the host are likely to be more relevant, whereas with passing time factors intrinsic to the cells predominate. At a minimum, we recommend that a comprehensive molecular cytogenetic assessment be performed at diagnosis, together with conventional evaluation, including beta2-microglobulin and albumin. In addition, information on proliferative activity of plasma cells may be of value. The introduction of novel methods of prognostication should be strongly considered in all clinical trials.

Immunoglobulin gene rearrangements and the pathogenesis of multiple myeloma

The ability to rearrange the germ-line DNA to generate antibody diversity is an essential prerequisite for the production of a functional repertoire. While this is essential to prevent infections, it also represents the “Achilles heal” of the B-cell lineage, occasionally leading to malignant transformation of these cells by translocation of protooncogenes into the immunoglobulin (Ig) loci. However, in evolutionary terms this is a small price to pay for a functional immune system. The study of the configuration and rearrangements of the Ig gene loci has contributed extensively to our understanding of the natural history of development of myeloma. In addition to this, the analysis of Ig gene rearrangements in B-cell neoplasms provides information about the clonal origin of the disease, prognosis, as well as providing a clinical useful tool for clonality detection and minimal residual disease monitoring. Herein, we review the data currently available on both Ig gene rearrangements and protein patterns seen in myeloma with the aim of illustrating how this knowledge has contributed to our understanding of the pathobiology of myeloma.

Plasma cell growth fraction using Ki-67 antigen expression identifies a subgroup of multiple myeloma patients displaying short survival within the ISS stage I

The current most powerful prognostic model in Multiple Myeloma (MM) combines beta-2 microglobulin (b2m) with albumin, corresponding to the International Staging System (ISS). However, the prognosis of patients within the ISS stage I (high albumin and low b2m) may vary. Ki-67 is a nuclear protein associated with cell proliferation. We retrospectively evaluated the percentage of bone marrow plasma cells expressing Ki-67 antigen (Ki-67 index) in a series of 174 untreated MM patients at diagnosis. Median survival was 51, 41 and 20 months respectively, and median Ki-67 index was 3.0%, 6.1% and 6.5% in ISS stages I, II, and III respectively. Independently of ISS, Ki-67 index > or =4% was highly predictive of adverse prognosis. Ki-67 index correlated with markers of intrinsic malignancy and with markers of tumour burden. Within ISS stage I, median survival was of 31 months (RR of death 2.65) in patients with Ki-67 index > or =4%. Eventually, the combination of Ki-67 with b2m produced an efficient prognostic model, which appeared most effective in our series when compared with b2m and KI-67 with chromosome 13 deletion models. In this series, we demonstrated that a proliferation marker provides clear-cut additional survival prognostic information to b2m into the ISS model.

[Multiple myeloma]

Multiple myeloma is the second most common hematological malignancy. It is defined by the presence of monoclonal plasma cells capable to produce a monoclonal paraprotein causing clinical abnormalities such as anemia, renal insufficiency, hypercalcemia, or bone lesions. New chromosomal or molecular abnormalities have been identified allowing a better management. Multiple myeloma is treatable and, although it remains incurable, the patient prognosis and quality of life has notably improved, so it is not rare to see series with a median survival longer than 5 years. Even more, it is possible by now to expect improvements respect to the standard autologous stem cell transplantation. This must be attributed to the emergence of a number of new therapies entering clinical practice over the last 6 years: thalidomide (Thalidomid Pharmion, Boulder, CO, USA), lenalidomide (Revlimid, Celgene Corporation, Summit, NJ, USA) and bortezomib (Velcade, Janssen Pharmaceutica N.V., Belgium). Finally, we also will review the current clinical experience in supportive therapy, which has also contributed to the patient outcome improvement with approaches such as: new indications for dialysis, use of erythropoietin receptor stimulating agents and bisphosphonates, and new surgical therapies such as vertebroplastia and kyphoplastia.

Interphase fluorescence in situ hybridization in multiple myeloma and monoclonal gammopathy of undetermined significance without and with positive plasma cell identification: analysis of 192 cases from the Region of Southern Denmark

Interphase fluorescence in-situ hybridization (i-FISH) was used to investigate 192 patients with multiple myeloma (MM; n = 182) and benign monoclonal gammopathy of undetermined significance (MGUS; n = 10). Of the 182 MM cases, 132 were investigated without and 50 with positive plasma cell identification (PC-ID+); 134 were investigated at diagnosis, 32 at time of progression, 7 at time of relapse, and 9 were investigated with partial remission or no response. The FISH analysis detected 11q23 (n = 61), 13q13 approximately q14 (n = 181), 14q32 (n = 121), 17p13.1 (n = 181), t(4;14) (n = 76), and t(11;14) (n = 73). Of the 132 patients investigated without PC-ID+, 61 (46%) showed chromosomal abnormalities, compared with 45 of 49 of evaluable cases (92%) with PC-ID+. The increase in abnormal cases identified was due mainly to the detection of more cases with 13q-, 17p-, and der(14)(q32). G-banding cytogenetics was performed in 72 patients; abnormalities were revealed in 19 cases (26%). Concordance between G-banding and i-FISH for one or more aberrations was found in 14 patients. Translocation (11;14) was detected by both methods in four of five cases. In four out of seven cases with either near-tetraploidy/triploidy or hypoploidy in the G-banded karyotypes, the modal number in the G-banded karyotypes could not be elucidated with certainty with i-FISH. Three of the 10 MGUS patients showed abnormalities. In conclusion, PC-ID+ is important for the detection of structural aberrations and disclosing translocations involving 14q32. Of these, translocations t(4;14) constituted 9% and t(11;14), 20%. Finally, based on the small number of cytogenetically abnormal cases, it is recommended to include cytogenetics (and, for example, the DNA index) in the prognostic armamentarium.

Chromosomal abnormalities of young multiple myeloma patients (<45 yr) are not different from those of other age groups and are independent of stage according to the International Staging System

Little is known about tumor-related prognostic factors, in particular specific chromosomal abnormalities, in young patients with multiple myeloma (MM). We therefore investigated the chromosomal pattern by interphase fluorescence in situ hybridization (chromosomes 13q14, 14q32-translocations, chromosomes associated with hyperdiploidy) in 38 young patients with MM (age <45 yr) and compared the results with those observed in 69 patients with intermediate age (45-70 yr) and 64 elderly patients (age >70 yr). All chromosomal patterns were not significantly different between the three age cohorts. Similarly, standard MM parameters were equally distributed between these MM patient populations. However, survival by the International Staging System (ISS) for MM revealed marked differences between stage I/II (median survival not yet reached) and stage III (23.4 months; P < 0.0003) among young MM patients. A significant survival difference between ISS-stage I/II and ISS-stage III patients was also noted in the intermediate age group (median 65.4 months vs. 24.6 months; P = 0.0009). However, this difference disappeared among elderly MM patients (39.6 months in ISS-stage I/II vs. 32 months in ISS-stage III patients; P = 0.94), but it was unrelated to the cytogenetic pattern. Our results indicate that MM in young patients does not represent a distinct biologic entity, and that short survival of younger MM patients at ISS-stage III is independent of the molecular cytogenetic pattern.

Risk Stratification of Patients with Newly Diagnosed Multiple Myeloma: Optimizing Treatment Based on Pretreatment Characteristics

Marked clinical and biologic heterogeneity exists in multiple myeloma (MM). Over the years, many prognostic factors have been identified and several prognostic systems have been proposed. The integration of data from international groups including patients treated with common modalities such as chemotherapy and high-dose therapy culminated in the International Staging System. Recently, genetic information has also been shown to include powerful prognostic factors across different treatment modalities. These advances have facilitated categorization of patients into different risk groups, particularly a subset of patients at high risk with short survival times after current standard therapy. The expanding armamentarium of effective treatments in MM also means that it is now possible to select treatments for patients based on their risk categories. This review will summarize the important prognostic factors identified to date, how they can be used to identify patients at high risk, and their clinical utility in relation to treatment optimization at diagnosis.

Imaging techniques used in the diagnosis, staging, and follow-up of patients with myeloma

Radiologists play a central role in the diagnosis, initial staging, follow-up, and restaging of patients with myeloma. This review article attempts to familiarize the reader with all the various types of myeloma, their imaging appearances and useful imaging strategies. The staging system for myeloma patients has been updated and now includes findings from advanced imaging modalities. Radiologists have a vast array of imaging modalities at their disposal to aid them in diagnosis, staging, and follow-up. Currently, conventional radiographic skeletal surveys, magnetic resonance imaging, and F-18 FDG PET/CT examinations are the most useful instruments.

Prognostic features of multiple myeloma

The outcome of myeloma patients is highly heterogeneous, with survival ranging from a few months to more than 10 years. Accordingly, investigation of prognostic factors may contribute to identification of risk categories and to provision of more accurate information about individual disease outcome. For many years prognostic factors have relied on clinical parameters such as age, hemoglobin level and renal function. Subsequently, biological parameters such as the proliferative activity of plasma cells and beta2-microglobulin have been added to the prognostic arsenal. More recently, cytogenetic and molecular markers with significant influence on disease outcome have been identified. Here we will review the most relevant prognostic factors reported in the literature in patients treated with both conventional chemotherapy and high-dose therapy followed by autologous stem-cell support, as well as in asymptomatic MM and MGUS patients.