Prognostic features of multiple myeloma

Clinical implications and predictive value of the creatinine‑cystatin C ratio in patients with multiple myeloma and renal impairment

The creatinine (Cr)-cystatin C ratio (CCR) at the time of cancer diagnosis is associated with survival; however, to the best of our knowledge, the association between this ratio and mortality in patients with multiple myeloma and renal impairment (RI) is unclear. Therefore, the present study aimed to assess this association, as well as disease prognosis and the clinical significance of the CCR in patients with multiple myeloma and RI. The present retrospective study included 191 patients diagnosed with multiple myeloma and RI between 2012 and 2022. The predictive value of the CCR was evaluated using area under the receiver operating characteristic curve (AUC) values. The factors affecting overall survival (OS) were assessed using uni- and multivariate logistic regression analyses. The effect of the CCR on survival was evaluated using a Cox regression model and the Kaplan-Meier method. There was a significant association between low CCR and poor progression-free survival (PFS) and overall survival (OS). The 1-, 2- and 3-year PFS and OS rates in patients with a low CCR were significantly lower than those in patients with a high CCR. The 1-, 2- and 3-year AUC values of the CCR were 0.712, 0.764 and 0.746 respectively. Multivariate analysis revealed sex, age, Cr levels, CCR and C-reactive protein levels as independent prognostic factors affecting OS rates. The CCR is a potential prognostic indicator in patients with multiple myeloma with RI and is associated with clinical stages.

The levels of serum soluble CD86 are correlated with the expression of CD86 variant 3 gene and are prognostic indicators in patients with myeloma

We previously showed that cell-surface CD86 expressed on multiple myeloma (MM) cells contributed to not only tumor growth but also antitumor cytotoxic T-lymphocyte responses mediated by induction of IL-10-producing CD4⁺ T cells. The soluble form of CD86 (sCD86) was also detected in serum from patients with MM. Thus, to determine whether sCD86 levels are a useful prognostic factor, we investigated the association of serum sCD86 levels with disease progression and prognosis in 103 newly diagnosed patients with MM. Serum sCD86 was detected in 71% of the patients with MM but was only rarely detected in patients with monoclonal gammopathy of undetermined significance and healthy controls, and the level was significantly increased in patients with advanced-stage MM. When we examined differences in clinical characteristics according to the level of serum sCD86, those in the high (≥2.18 ng/mL, n = 38) group exhibited more aggressive clinical characteristics, with shorter overall survival times compared with those in the low (<2.18 ng/mL, n = 65) group. On the other hand, it was difficult to stratify the patients with MM into different risk groups based on the expression levels of cell-surface CD86. The levels of serum sCD86 were significantly correlated with the expression levels of the messenger RNA (mRNA) transcripts of CD86 variant 3, which lack exon 6, resulting in a truncated transmembrane region, and its variant transcripts were upregulated in the high group. Thus, our findings suggest that sCD86 can be easily measured in peripheral blood samples and is a useful prognostic marker in patients with MM.

Body Mass Index and Overall Survival of Patients with Newly Diagnosed Multiple Myeloma

Obesity is associated with survival in several solid tumors and non-Hodgkin lymphoma, but its impact on multiple myeloma (MM) survival is unclear. We examined the associations between body mass index (BMI) at different periods of life up to the time of diagnosis and overall survival (OS) among 563 patients newly diagnosed with MM in 2010–2019. BMI at diagnosis was calculated using measured height and weight from electronic medical records (EMR). BMIs at age 20, maximum during adulthood, and 5 years before diagnosis were calculated using self-reported weights and measured height from EMR. Over a median follow-up of 49.3 months, 191 (33.93%) deaths were identified. We used multivariable Cox proportional-hazards models to examine the associations between BMIs and OS. Height as well as BMI before and at diagnosis was not associated with OS, but there is a U-shape association between weight and OS. Higher BMIs at diagnosis were associated with better OS among females (HR = 0.39 [0.22–0.71]), irrespective of race. In conclusion, our results suggest that BMI at different periods of life up to the time of diagnosis may not be associated with OS in MM, except that a higher BMI at diagnosis was associated with superior OS for females.

The Biological Role and Therapeutic Potential of NK Cells in Hematological and Solid Tumors

NK cells are an attractive target for cancer immunotherapy due to their potent antitumor activity. The main advantage of using NK cells as cytotoxic effectors over T cells is a reduced risk of graft versus host disease. At present, several variants of NK-cell-based therapies are undergoing clinical trials and show considerable effectiveness for hematological tumors. In these types of cancers, the immune cells themselves often undergo malignant transformation, which determines the features of the disease. In contrast, the current use of NK cells as therapeutic agents for the treatment of solid tumors is much less promising. Most studies are at the stage of preclinical investigation, but few progress to clinical trials. Low efficiency of NK cell migration and functional activity in the tumor environment are currently considered the major barriers to NK cell anti-tumor therapies. Various therapeutic combinations, genetic engineering methods, alternative sources for obtaining NK cells, and other techniques are aiming at the development of promising NK cell anticancer therapies, regardless of tumorigenesis. In this review, we compare the role of NK cells in the pathogenesis of hematological and solid tumors and discuss current prospects of NK-cell-based therapy for hematological and solid tumors.

The role of cystatin C in multiple myeloma

INTRODUCTION

Renal insufficiency is one of the common complications in multiple myeloma (MM) and an independent factor indicating a poor prognosis. Cystatin C (Cys C) is considered to be expected to replace creatinine to calculate glomerular filtration rate due to its own characteristics. Gene expression analysis suggested that cystatin C is up-regulated nearly 50-fold in patients with multiple myeloma.

METHODS

To further clarify the role of cystatin C in multiple myeloma, we retrospectively evaluated pretreatment cystatin C levels in 195 newly diagnosed patients through statistical analysis.

RESULTS

The elevation of serum cystatin C was positively related to the elevation of serum creatinine (P < .001), LDH (P = .006), β2-microglobulin (P < .001), bone marrow plasma cell proportion (P = .005) and the reduction of hemoglobin levels (P < .001). Patients with serum cystatin C levels >1.6 mg/L had a significantly shorter progression-free survival (PFS) or overall survival (OS) than patients with serum cystatin C levels <1.6 mg/L (median PFS: median unreached vs 16.7 months, P < .001; median OS: 68 months vs 42 months, P = .014). Although serum cystatin C is not an independent prognostic factor of OS and PFS in patients with multiple myeloma, serum cystatin C can be considered as a sensitive indicator to differentiate well OS and PFS in the group of ISS II patients.

CONCLUSION

Serum cystatin C is associated with tumor burden of multiple myeloma and cystatin C can further differentiate the prognosis of ISS II patients. More prospective studies are required to explore the role of serum cystatin C in multiple myeloma.

NK Cells in the Treatment of Hematological Malignancies

Natural killer (NK) cells have the innate ability to kill cancer cells, however, tumor cells may acquire the capability of evading the immune response, thereby leading to malignancies. Restoring or potentiation of this natural antitumor activity of NK cells has become a relevant therapeutic approach in cancer and, particularly, in hematological cancers. The use of tumor-specific antibodies that promote antibody-dependent cell-mediated cytotoxicity (ADCC) through the ligation of CD16 receptor on NK cells has become standard for many hematologic malignancies. Hematopoietic stem cell transplantation is another key therapeutic strategy that harnesses the alloreactivity of NK cells against cancer cells. This strategy may be refined by adoptive transfer of NK cells that may be previously expanded, activated, or redirected (chimeric antigen receptor (CAR)-NK cells) against cancer cells. The antitumor activity of NK cells can also be boosted by cytokines or immunostimulatory drugs such as lenalidomide or pomalidomide. Finally, targeting immunosubversive mechanisms developed by hematological cancers and, in particular, using antibodies that block NK cell inhibitory receptors and checkpoint proteins are novel promising therapeutic approaches in these malignant diseases.

Evaluation of in vitro effects of various targeted drugs on plasma cells and putative neoplastic stem cells in patients with multiple myeloma

Multiple myeloma (MM) is a malignancy characterized by monoclonal paraproteinemia and tissue plasmocytosis. In advanced MM cytopenia and osteopathy may occur. Although several effective treatment strategies have been developed in recent years, there is still a need to identify new drug targets and to develop more effective therapies for patients with advanced MM. We examined the effects of 15 targeted drugs on growth and survival of primary MM cells and 5 MM cell lines (MM.1S, NCI-H929, OPM-2, RPMI-8226, U-266). The PI3-kinase blocker BEZ235, the pan-BCL-2 inhibitor obatoclax, the Hsp90-targeting drug 17AAG, and the Polo-like kinase-1 inhibitor BI2536, were found to exert major growth-inhibitory effects in all 5 MM cell lines tested. Moreover, these drugs suppressed the in vitro proliferation of primary bone marrow-derived MM cells and induced apoptosis at pharmacologic drug concentrations. Apoptosis-inducing effects were not only seen in the bulk of MM cells but also in MM stem cell-containing CD138⁻/CD20⁺/CD27⁺ memory B-cell fractions. Synergistic growth-inhibitory effects were observed in MM cell lines using various drug combinations, including 17AAG+BI2536 in MM.1S, OPM-2, RPMI-8226, and U-266 cells, 17AAG+BEZ235 in MM.1S, OPM-2, RPMI-8226, and U-266 cells, 17AAG+obatoclax in MM.1S, NCI-H929, OPM-2, and RPMI-8226 cells, BI2536+BEZ235 in MM.1S, NCI-H929, OPM-2, and RPMI-8226 cells, BI2536+obatoclax in MM.1S, OPM-2 and RPMI-8226 cells, and BEZ235+obatoclax in MM.1S and RPMI-8226 cells. Together, our data show that various targeted drugs induce profound and often synergistic anti-neoplastic effects in MM cells which may have clinical implications and may contribute to the development of novel treatment strategies in advanced MM.

Detection of 14q32 rearrangements in multiple myeloma, using simultaneous FISH analysis combined with immunofluorescence

BACKGROUND

14q32 rearrangement has been identified as a recurrent hotspot of translocations in multiple myeloma (MM). The Fluorescence Immunophenotyping and Interphase Cytogenetics as a tool for the Investigation of Neoplasms (known as FICTION technique) for evaluation of chromosomal changes in MM. The aim of this work is to detect 14q32 rearrangement, using FICTION technique, on archival bone marrow (BM) slides of MM patients, and to study its prognostic value.

METHOD

This study was conducted at Ain Shams University Hospital. The FICTION technique, which uses CD138 and dual color, and the break-apart 14q32 rearrangement probe, was performed on archived smears of BM slides for 50 MM patients at the time of diagnosis.

RESULTS

A significantly higher percentage of cases were positive for 14q32 rearrangement by FICTION (32%) compared to fluorescence in situ hybridization (FISH) (12%) (p=0.04). Cases positive by FICTION for the rearrangement were designated as Group A, while negative cases were designated as Group B. Significantly lower Hb and CRP levels were found among Group B when compared to Group A patients (p=0.001 and 0.01, respectively). Serum albumin level and Bence Jones protein (BJP) significantly affect overall survival (OS) (p=0.01, 0.007, respectively). However, a statistically non-significant shorter mean survival time was found in positive cases through FICTION versus negative cases.

CONCLUSION

FICTION technique provides a sensitive tool for establishing clonal plasma cells (PC) infiltration of BM aspirates, and is amenable for use on archived as well as fresh smears.

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.

Renal failure in multiple myeloma: Incidence, correlations, and prognostic significance

Renal failure (RF) is a common and severe complication of patients with multiple myeloma (MM). The purpose of our study was to assess the incidence of RF in a contemporary series of newly diagnosed patients with MM, its association with specific clinical and laboratory features, and its impact on patients' outcome. Over the last decade, 756 newly diagnosed symptomatic patients with MM were included in our database. Renal failure, defined as a serum creatinine >or= 2 mg/dl at the time of diagnosis, was seen in 21% of patients. Multiple parameters were associated with RF, but logistic regression analysis showed that RF was independently associated only with International Staging System and Bence Jones proteinuria. The presence of RF was associated with a trend for higher early death rate but with a similar response to primary therapy. The median survival of patients with RF was 19.5 months versus 40.4 months for patients without RF (p < 0.001). Several variables were associated with impaired survival by univariate analysis. When multivariate analysis was performed the independent variables were poor performance status, thrombocytopenia, advanced age, high LDH and elevated serum beta2 microglobulin but not high creatinine. When corrected for stage, renal failure had no impact on survival.

Cystatin-C is an independent prognostic factor for survival in multiple myeloma and is reduced by bortezomib administration

BACKGROUND

Renal impairment is a common complication of multiple myeloma. Cystatin-C is considered an accurate marker of glomerular filtration rate in several renal disorders. Microarray analysis has revealed that cystatin-C is one of the most highly up-regulated genes in multiple myeloma. The aim of this study was to evaluate the serum levels of cystatin-C in myeloma patients, explore possible correlations with clinical data, including survival, and assess the effect of bortezomib on cystatin-C in relapsed multiple myeloma.

DESIGN AND METHODS

We measured serum cystatin-C in 157 newly diagnosed, previously untreated myeloma patients, in 28 patients with relapsed disease pre- and post-bortezomib therapy and in 52 healthy controls, using a latex particle-enhanced nephelometric immunoassay.

RESULTS

In newly diagnosed patients, cystatin-C was elevated and showed strong correlations with advanced ISS stage, extensive bone disease, high beta(2)-microglobulin, high serum creatinine, and low creatinine clearance. Multivariate analysis revealed that only cystatin-C and lactate dehydrogenase had an independent prognostic impact on patients' survival. The combination of cystatin-C and lactate dehydrogenase revealed three prognostic groups of patients: a high-risk group (both elevated cystatin-C and lactate dehydrogenase) with a median survival of 24 months, an intermediate-risk group (elevated cystatin-C or elevated lactate dehydrogenase) with a median survival of 48 months and a low-risk group (both low cystatin-C and lactate dehydrogenase) in which median survival has not yet been reached (p<0.001). Cystatin-C could also identify a subset of ISS-II patients with worse outcome. Relapsed patients had higher cystatin-C levels even compared to newly diagnosed patients. Treatment with bortezomib produced a significant reduction of cystatin-C, mainly in responders.

CONCLUSIONS

Serum cystatin-C is not only a sensitive marker of renal impairment but also reflects tumor burden and is of prognostic value in myeloma. Its reduction after treatment with bortezomib reflects bortezomib's anti-myeloma activity and possibly bortezomib's direct effect on renal function.

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.

[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.

Autologous stem cell transplantation is safe and feasible in elderly patients with multiple myeloma

Several clinical trials have shown the superiority of autologous stem cell transplantation over conventional dose therapy for patients with multiple myeloma. This treatment, however, is limited to younger patients (<65 years) owing to concerns about toxicity and treatment-related mortality (TRM) in older patients. We treated 26 elderly myeloma patients (>70 years), who received a preparative regimen of melphalan 200 mg/m2 (19 patients), melphalan 180 mg/m2 (six patients) or melphalan 140 mg/m2 (one patient). Twenty-two of the 26 patients were alive after a median follow-up of 25 months (range=8-74). Responses (complete+partial response) were seen in 20 patients (77%), five (19%) of which were complete responses. Median PFS was 24 months, whereas median OS has not been reached. Cumulative incidence of 100-day TRM was 0%. Three-year PFS and OS were 39% (range=16-61) and 65% (range=35-83), respectively. A low serum albumin (<3.5 g/dl) was associated with a shorter PFS (P=0.02). Patients with relapsed disease at transplant, and an interval of >12 months between diagnosis and autotransplant, had a shorter OS (P=0.0004 and 0.04). HDT and autologous transplant is safe and feasible in elderly myeloma patients.

Prognostic and biological implications of genetic abnormalities in multiple myeloma undergoing autologous stem cell transplantation: t(4;14) is the most relevant adverse prognostic factor, whereas RB deletion as a unique abnormality is not associated with adverse prognosis

Fluorescence in situ hybridization (FISH) has become a powerful technique for prognostic assessment in multiple myeloma (MM). However, the existence of associations between cytogenetic abnormalities compels us to re-assess the value of each abnormality. A total of 260 patients with MM at the time of diagnosis, enrolled in the GEM-2000 Spanish transplant protocol, have been analyzed by FISH in order to ascertain the independent influence on myeloma prognosis of IGH translocations, as well as RB and P53 deletions. Survival analyses showed that patients with t(4;14), RB or P53 deletions had a significantly shorter survival than patients without these abnormalities. However, patients with RB deletions without other abnormalities in FISH analysis, displayed a similar outcome to those patients without genetic changes by FISH (46 vs 54 months, P=0.3). In the multivariate analysis the presence of t(4;14), RB deletion associated with other abnormalities, age >60 years, high proportion of S-phase cells and advanced stage of the disease according to the International Staging System retained their independent prognostic influence. In summary, RB deletion as a sole abnormality does not lead to a shortening in the survival of MM patients, whereas t(4;14) confers the worst prognosis in MM patients treated with high-dose chemotherapy.

Clinical implications of chromosomal abnormalities in multiple myeloma

The adverse prognostic role of cytogenetic abnormalities has recently been established in plasma cell dyscrasias. Modern techniques such as fluorescence in situ hybridization and comparative genomic hybridization have revealed a higher incidence of cytogenetic abnormalities in patients with multiple myeloma (MM) compared to conventional cytogenetics. Hypodiploidy and chromosome 13 abnormalities are found in more than 50% of myeloma patients, representing well known factors with adverse prognosis. Rearrangements involving the switch regions of immunoglobulin heavy chain (IgH) gene at 14q32 with various partner genes represent the most common structural abnormalities, having an incidence of 70% in MM. Structural abnormalities of chromosomes 17 and 8 involving the p53 and c-myc genes are considered to be less frequent events, but carry a poor prognosis. New therapeutic approaches such as non-myeloablative allotransplantation and modern therapeutic agents (thalidomide, lenalidomide, and bortezomib) and their combinations give promise for an improved therapeutic management of patients with MM. The detection of t(4;14), t(14;16), deletion of chromosome 13 on metaphase analysis, or deletion of p53 by FISH will define high-risk prognostic groups that are not generally controlled with high-dose melphalan and autologous stem cell transplantation (ASCT), and should therefore be treated with more investigational therapies. Alternatively, eligible patients who do not have these poor risk factors are more likely to benefit from a high-dose, melphalan-based, regimen followed by ASCT.

Conventional diagnostics in multiple myeloma

This paper reviews the most relevant laboratory techniques currently used for the evaluation of patients with multiple myeloma (MM) and other monoclonal gammopathies. Although the bone marrow morphological examination and electrophoretic analysis of the monoclonal paraprotein still remain the 'gold standard' techniques for fast, accurate and cost-effective diagnosis, other assays such as immunophenotyping, DNA cell content and cell cycle analysis measured by flow cytometry may contribute to a better assessment of myeloma patients. Here, we will discuss not only the contribution of each technique to differential diagnosis of monoclonal gammopathies, but also the value of each parameter as prognostic factor and for monitoring treatment efficacy. In addition, possible technical pitfalls inherent to each technique will be analysed.