Prognostic value of bone marrow angiogenesis in patients with multiple myeloma undergoing high-dose therapy

Association of Cellular Cannibalism with Immunohistochemical Expression of CD31, CD68 and BCL2 in Oral Squamous Cell Carcinoma: An Observational Study

Objective

Cellular cannibalism (CC) is a prime metabolic event to determine the aggressive potential of oral squamous cell carcinoma (OSCC). However, the etiology and mechanism behind this degradation are still ambiguous. The aim of the study was to explore the etiopathogenetic mechanism behind CC, along with its association with degree of differentiation, angiogenic, phagocytic and antiapoptotic activity in OSCC.

Design

Seventy-three tissue sections of various histological grades of OSCC were retrieved from departmental archives and scanned for cannibalistic cells. Immunohistochemical analysis using CD31, CD68, and BCL2 was performed. The data obtained were analyzed using Chi-square, Spearman's correlation test and multiple regression analysis (p < 0.05).

Results

CCs were present significantly in various grades of OSCC (p < 0.00). Immunohistochemical analysis revealed a significant difference in CD68, BCL2 (p < 0.05 in both), and CD31 (p < 0.001) expression with CC. The internalized cells showed positivity for CD68 and negativity for BCL2. Regression analysis revealed that tumor grade, CD31 and BCL2 immunoreactivity were significant predictors of frequency of CC.

Conclusion

The association of CC with degree of differentiation, CD31, CD68, and BCL2 expression could predict the biological behavior of OSCC and might serve as a promising histopathological parameter in future.

Adverse impact of delay of platelet recovery after autologous hematopoietic cell transplantation for aggressive non-Hodgkin lymphoma and multiple myeloma

BACKGROUND AIMS

The prognostic impact of platelet recovery after autologous hematopoietic cell transplantation (AHCT) on clinical outcomes remains to be elucidated. We aimed to clarify the impact of platelet recovery on clinical outcomes, risk factors of delayed platelet recovery and the necessary dose of CD34+ cells for prompt platelet recovery in each patient.

METHODS

Using a nationwide Japanese registry database, we retrospectively analyzed clinical outcomes of 5222 patients with aggressive non-Hodgkin lymphoma (NHL) or multiple myeloma (MM).

RESULTS

At a landmark of 28 days after AHCT, a delay of platelet recovery was observed in 1102 patients (21.1%). Prompt platelet recovery was significantly associated with superior overall survival (hazard ratio [HR] 0.32, P < 0.001), progression-free survival (HR 0.48, P < 0.001) and decreased risks of disease progression (HR 0.66, P < 0.001) and non-relapse/non-progression mortality (HR 0.19, P < 0.001). The adverse impacts of a delay of platelet recovery seemed to be more apparent in NHL. In addition to the dose of CD34+ cells/kg, disease status, performance status and the hematopoietic cell transplant-specific comorbidity index in both diseases were associated with platelet recovery. We then stratified the patients into three risk groups according to these factors. For the purpose of achieving 70% platelet recovery by 28 days in NHL, the low-, intermediate- and high-risk groups needed more than 2.0, 3.0 and 4.0 × 106 CD34+ cells/kg, respectively. In MM, the low-risk group needed approximately 1.5 × 106 CD34+ cells/kg, whereas the intermediate- and high-risk groups required 2.0 and 2.5 × 106 CD34+ cells/kg to achieve about 80% platelet recovery by 28 days.

CONCLUSIONS

A delay of platelet recovery after AHCT was associated with inferior survival outcomes.

Anti-Angiogenic Activity of Drugs in Multiple Myeloma

Angiogenesis represents a pivotal hallmark of multiple myeloma (MM) that correlates to patients’ prognosis, overall survival, and drug resistance. Hence, several anti-angiogenic drugs that directly target angiogenic cytokines (i.e., monoclonal antibodies, recombinant molecules) or their cognate receptors (i.e., tyrosine kinase inhibitors) have been developed. Additionally, many standard antimyeloma drugs currently used in clinical practice (i.e., immunomodulatory drugs, bisphosphonates, proteasome inhibitors, alkylating agents, glucocorticoids) show anti-angiogenic effects further supporting the importance of inhibiting angiogenesis from potentiating the antimyeloma activity. Here, we review the most important anti-angiogenic therapies used for the management of MM patients with a particular focus on their pharmacological profile and on their anti-angiogenic effect in vitro and in vivo. Despite the promising perspective, the direct targeting of angiogenic cytokines/receptors did not show a great efficacy in MM patients, suggesting the need to a deeper knowledge of the BM angiogenic niche for the design of novel multi-targeting anti-angiogenic therapies.

What's Old is New: The Past, Present and Future Role of Thalidomide in the Modern-Day Management of Multiple Myeloma

Immunomodulatory drugs (IMiDs) have become an integral part of therapy for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM). IMiDs bind to cereblon, leading to the degradation of proteins involved in B-cell survival and proliferation. Thalidomide, a first-generation IMiD, has little to no myelosuppressive potential, negligible renal clearance, and long-proven anti-myeloma activity. However, thalidomide's adverse effects (e.g., somnolence, constipation, and peripheral neuropathy) and the advent of more potent therapeutic options has led to the drug being less frequently used in many countries, including the US and Canada. Newer-generation IMiDs, such as lenalidomide and pomalidomide, are utilized far more frequently. In numerous previous trials, salvage therapy with thalidomide (50-200 mg/day) plus corticosteroids (with or without selected cytotoxic or targeted agents) has been shown to be effective and well-tolerated in the RRMM setting. Hence, thalidomide-based regimens remain important alternatives for heavily pretreated patients, especially for those who have no access to novel therapies and/or are not eligible for their use (due to renal failure, high-grade myelosuppression, or significant comorbidities). Ongoing and future trials may provide further insights into the current role of thalidomide, especially by comparing thalidomide-containing regimens with protocols based on newer-generation IMiDs and by investigating thalidomide's association with novel therapies (e.g., antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T cells).

JunB is a key regulator of multiple myeloma bone marrow angiogenesis

Bone marrow (BM) angiogenesis significantly influences disease progression in multiple myeloma (MM) patients and correlates with adverse prognosis. The present study shows a statistically significant correlation of the AP-1 family member JunB with VEGF, VEGFB, and IGF1 expression levels in MM. In contrast to the angiogenic master regulator Hif-1α, JunB protein levels were independent of hypoxia. Results in tumor-cell models that allow the induction of JunB knockdown or JunB activation, respectively, corroborated the functional role of JunB in the production and secretion of these angiogenic factors (AFs). Consequently, conditioned media derived from MM cells after JunB knockdown or JunB activation either inhibited or stimulated in vitro angiogenesis. The impact of JunB on MM BM angiogenesis was finally confirmed in a dynamic 3D model of the BM microenvironment, a xenograft mouse model as well as in patient-derived BM sections. In summary, in continuation of our previous study (Fan et al., 2017), the present report reveals for the first time that JunB is not only a mediator of MM cell survival, proliferation, and drug resistance, but also a promoter of AF transcription and consequently of MM BM angiogenesis. Our results thereby underscore worldwide efforts to target AP-1 transcription factors such as JunB as a promising strategy in MM therapy.

Emerging protein kinase inhibitors for the treatment of multiple myeloma

Introduction: Significant advances have been made during the last two decades in terms of new therapeutic options but also of innovative approaches to diagnosis and management of multiple myeloma (MM). While patient survival has been significantly prolonged, most patients relapse. Including the milestone approval of the first kinase inhibitor imatinib mesylate for CML in 2001, 48 small molecule protein kinase (PK) inhibitors have entered clinical practice until now. However, no PK inhibitor has been approved for MM therapy yet. Areas covered: This review article summarizes up-to-date knowledge on the pathophysiologic role of PKs in MM. Derived small molecules targeting receptor tyrosine kinases (RTKs), the Ras/Raf/MEK/MAPK- pathway, the PI3K/Akt/mTOR- pathway as well as Bruton tyrosine kinase (BTK), Aurora kinases (AURK), and cyclin-dependent kinases (CDKs) are most promising. Preclinical as well as early clinical data focusing on these molecules will be presented and critically reviewed. Expert opinion: Current MM therapy is directed against general vulnerabilities. Novel therapeutic strategies, inhibition of PKs in particular, are directed to target tumor-specific driver aberrations such as genetic abnormalities and microenvironment-driven deregulations. Results of ongoing Precision Medicine trials with PK inhibitors alone or in combination with other agents are eagerly awaited and hold the promise of once more improving MM patient outcome.

Bone Marrow CX3CL1/Fractalkine is a New Player of the Pro-Angiogenic Microenvironment in Multiple Myeloma Patients

C-X3-C motif chemokine ligand 1 (CX3CL1)/fractalkine is a chemokine released after cleavage by two metalloproteases, ADAM metallopeptidase domain 10 (ADAM10) and ADAM metallopeptidase domain 17 (ADAM17), involved in inflammation and angiogenesis in the cancer microenvironment. The role of the CX3CL1/ C-X3-C motif chemokine receptor 1(CX3CR1) axis in the multiple myeloma (MM) microenvironment is still unknown. Firstly, we analyzed bone marrow (BM) plasma levels of CX3CL1 in 111 patients with plasma cell disorders including 70 with active MM, 25 with smoldering myeloma (SMM), and 16 with monoclonal gammopathy of undetermined significance (MGUS). We found that BM CX3CL1 levels were significantly increased in MM patients compared to SMM and MGUS and correlated with BM microvessel density. Secondly, we explored the source of CX3CL1 in MM and BM microenvironment cells. Primary CD138⁺ cells did not express CXC3L1 but up-regulated its production by endothelial cells (ECs) through the involvement of tumor necrosis factor alpha (TNFα). Lastly, we demonstrated the presence of CX3CR1 on BM CD14⁺CD16⁺ monocytes of MM patients and on ECs, but not on MM cells. The role of CX3CL1 in MM-induced angiogenesis was finally demonstrated in both in vivo chick embryo chorioallantoic membrane and in vitro angiogenesis assays. Our data indicate that CX3CL1, present at a high level in the BM of MM patients, is a new player of the MM microenvironment involved in MM-induced angiogenesis.

Maintaining therapeutic progress in multiple myeloma by integrating genetic and biological advances into the clinic

INTRODUCTION

Utilizing advances in genetic and immunologic analysis to segment and direct treatment is potentially a way of maintaining therapeutic progress toward cure in multiple myeloma (MM). This approach works well using clinical segments but can be optimized using recent genetic and immunologic technologies, which have opened the possibility of enhancing risk stratification and disease subclassification. Areas covered: This position paper discusses strategies to segment myeloma into subgroups with distinct risk profiles and distinct targetable lesions are presented. Expert commentary: Risk stratified treatment of MM is already a clinical reality that can be enhanced by the developmental of unified segmentation and testing approaches. Mutation-targeted treatment has proven to be effective against the RAS pathway, but is compromised by intra-clonal and spatiotemporal heterogeneity. Identifying new disease segments based on tumor biology or immunological content of the microenvironment offers an exciting new way to control and even eradicate myeloma clones. Going forward, risk and biologically stratified therapy for myeloma is a promising way of maintaining therapeutic progress, as is precision immunotherapy directed by the cellular context of the bone marrow.

Bone Marrow Stroma and Vascular Contributions to Myeloma Bone Homing

PURPOSE OF THE REVIEW

Herein we dissect mechanisms behind the dissemination of cancer cells from primary tumor site to the bone marrow, which are necessary for metastasis development, with a specific focus on multiple myeloma.

RECENT FINDINGS

The ability of tumor cells to invade vessels and reach the systemic circulation is a fundamental process for metastasis development; however, the interaction between clonal cells and the surrounding microenvironment is equally important for supporting colonization, survival, and growth in the secondary sites of dissemination. The intrinsic propensity of tumor cells to recognize a favorable milieu where to establish secondary growth is the basis of the "seed and soil" theory. This theory assumes that certain tumor cells (the "seeds") have a specific affinity for the milieu of certain organs (the "soil"). Recent literature has highlighted the important contributions of the vascular niche to the hospitable "soil" within the bone marrow. In this review, we discuss the crucial role of stromal cells and endothelial cells in supporting primary growth, homing, and metastasis to the bone marrow, in the context of multiple myeloma, a plasma cell malignancy with the unique propensity to primarily grow and metastasize to the bone marrow.

Microvessel Density as a Surrogate Prognostic Marker in Patients with Multiple Myeloma: A Meta-Analysis

BACKGROUND/AIMS

Bone marrow (BM) angiogenesis is considered a hallmark of multiple myeloma (MM) development and progression, and can be quantified with the use of microvessel density (MVD). The purpose of this study is to provide a review and a meta-analysis of the current literature regarding the prognostic value of MVD in the overall survival (OS) of MM patients.

METHODS

MEDLINE was screened for studies evaluating the OS of MM patients with regard to their MVD count in BM trephine. The pooled hazard ratio (HR) and its associated 95% confidence interval (CI) among MM patients with a high and low MVD count was the primary end point. Secondary outcomes included odds ratios (OR) for 12-, 36-, and 60-month survival.

RESULTS

Ten eligible trials were identified for the analysis of the primary end point and 9 for the secondary end points. Pooled HR for OS was 1.85 (95% CI: 1.25-2.73, p = 0.002). The pooled OR of survival were 1.59 (95% CI: 1.02-2.46, p = 0.04) at 12 months, 2.90 (95% CI: 1.68-5.03, p = 0.0001) at 36 months, and 3.42 (95% CI: 2.41-4.85, p < 0.00001) at 60 months, in favor of the low MVD group.

CONCLUSION

This meta-analysis provides persuasive evidence that MVD has significant impact on the clinical outcome of MM patients.

Direct measurement of hypoxia in a xenograft multiple myeloma model by optical-resolution photoacoustic microscopy

Using photoacoustic microscopy (PAM), we evaluated non-invasively oxygenation and vascularization in vivo due to multiple myeloma (MM) progression. Mice injected with MM.1S-GFP were monitored with a fluorescence microscope for tumor progression. In vivo PAM of the cerebral bone marrow quantified the total oxygen saturation (sO₂). At 28 days after the MM cell injection, the total sO₂ had decreased by half in the developing tumor regions, while in the non-tumor regions it had decreased by 20% compared with the value at one day post MM injection. The blood vessel density was reduced by 35% in the developing tumor regions, while in the non-tumor regions it was reduced by 8% compared with the value at one day post MM injection. Hence, PAM corroborated the development of hypoxia due to MM progression and demonstrated decreased vascularization surrounding the tumor areas.

Integration of Genomics Into Treatment: Are We There Yet?

Using advances in genetic analysis to segment and direct treatment of multiple myeloma (MM) represents a way of maintaining therapeutic progress. Recent genetic analyses have opened the possibility of enhancing risk stratification approaches and of using different risk and biologic strata as part of clinical trials. The Myeloma Genome Project is a collaborative project that has compiled the largest set of cases with sequencing and have outcome data that are available for stratification purposes. Mutation-targeted treatment of the Ras pathway has been shown to be active in MM, but is compromised by the presence of the subclonal genetic variation typical of myeloma. Going forward, risk and biologically stratified therapy for MM looks to be a promising way of maintaining therapeutic progress, as does precision immunotherapy directed by the cellular context of the bone marrow.

Adverse prognostic impact of bone marrow microvessel density in multiple myeloma

Background

Angiogenesis is important for the proliferation and survival of multiple myeloma (MM) cells. Bone marrow (BM) microvessel density (MVD) is a useful marker of angiogenesis and is determined by immunohistochemical staining with anti-CD34 antibody. This study investigated the prognostic impact of MVD and demonstrated the relationship between MVD and previously mentioned prognostic factors in patients with MM.

Methods

The study included 107 patients with MM. MVD was assessed at initial diagnosis in a blinded manner by two hematopathologists who examined three CD34-positive hot spots per patient and counted the number of vessels in BM samples. Patients were divided into three groups according to MVD tertiles. Cumulative progression-free survival (PFS) and overall survival (OS) curves, calculated by using Kaplan-Meier method, were compared among the three groups. Prognostic impact of MVD was assessed by calculating Cox proportional hazard ratio (HR).

Results

Median MVDs in the three groups were 16.8, 33.9, and 54.7. MVDs were correlated with other prognostic factors, including β2-microglobulin concentration, plasma cell percentage in the BM, and cancer stage according to the International Staging System. Multivariate Cox regression analysis showed that high MVD was an independent predictor of PFS (HR=2.57; 95% confidence interval, 1.22-5.42; P=0.013). PFS was significantly lower in the high MVD group than in the low MVD group (P=0.025). However, no difference was observed in the OS (P=0.428).

Conclusions

Increased BM MVD is a marker of poor prognosis in patients newly diagnosed with MM. BM MVD should be assessed at the initial diagnosis of MM.

Raiders of the lost mark - endothelial cells and their role in transplantation for hematologic malignancies

Endothelial cells (EC) are crucial for normal angiogenesis and important for patients with leukemia, myeloma, and lymphoma during and after hematopoietic stem cell transplantation (HSCT). Knowledge of endothelial dysfunction in hematologic malignancies is provided by translational studies analyzing soluble endothelial markers, morphologic and functional changes of EC cultured in patients' sera or enumeration of circulating EC or endothelial progenitor cells (EPC). EC are important for stem cell homing and maintenance. Endothelial activation or damage is a central component in the pathogenesis of several complications after HSCT, like acute and chronic graft-versus-host disease, sinusoidal obstruction syndrome, capillary leak syndrome, engraftment syndrome, diffuse alveolar syndrome, idiopathic pneumonia syndrome, and transplant-associated microangiopathy. Finally, EC or EPC may facilitate tumor cell survival thus representing potential factors for both disease progression and relapse in hematologic malignancies.

Galectin-1 suppression delineates a new strategy to inhibit myeloma-induced angiogenesis and tumoral growth in vivo

Galectin-1 (Gal-1) is involved in tumoral angiogenesis, hypoxia and metastases. Actually the Gal-1 expression profile in multiple myeloma (MM) patients and its pathophysiological role in MM-induced angiogenesis and tumoral growth are unknown. In this study, we found that Gal-1 expression by MM cells was upregulated in hypoxic conditions and that stable knockdown of hypoxia inducible factor-1α significantly downregulated its expression. Therefore, we performed Gal-1 inhibition using lentivirus transfection of shRNA anti-Gal-1 in human myeloma cell lines (HMCLs), and showed that its suppression modified transcriptional profiles in both hypoxic and normoxic conditions. Interestingly, Gal-1 inhibition in MM cells downregulated proangiogenic genes, including MMP9 and CCL2, and upregulated the antiangiogenic ones SEMA3A and CXCL10. Consistently, Gal-1 suppression in MM cells significantly decreased their proangiogenic properties in vitro. This was confirmed in vivo, in two different mouse models injected with HMCLs transfected with anti-Gal-1 shRNA or the control vector. Gal-1 suppression in both models significantly reduced tumor burden and microvascular density as compared with the control mice. Moreover, Gal-1 suppression induced smaller lytic lesions on X-ray in the intratibial model. Overall, our data indicate that Gal-1 is a new potential therapeutic target in MM blocking angiogenesis.

Pathogenesis beyond the cancer clone(s) in multiple myeloma

Over the past 4 decades, basic research has provided crucial information regarding the cellular and molecular biology of cancer. In particular, the relevance of cancer microenvironment (including both cellular and noncellular elements) and the concept of clonal evolution and heterogeneity have emerged as important in cancer pathogenesis, immunologic escape, and resistance to therapy. Multiple myeloma (MM), a cancer of terminally differentiated plasma cells, is emblematic of the impact of cancer microenvironment and the role of clonal evolution. Although genetic and epigenetic aberrations occur in MM and evolve over time under the pressure of exogenous stimuli, they are also largely present in premalignant plasma cell dyscrasia such as monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM), suggesting that genetic mutations alone are necessary, but not sufficient, for myeloma transformation. The role of bone marrow microenvironment in mediating survival, proliferation, and resistance to therapy in myeloma is well established; and although an appealing speculation, its role in fostering the evolution of MGUS or SMM into MM is yet to be proven. In this review, we discuss MM pathogenesis with a particular emphasis on the role of bone marrow microenvironment.

Dynamic contrast-enhanced magnetic resonance imaging for assessment of antiangiogenic treatment effects in multiple myeloma

PURPOSE

To noninvasively assess bone marrow microcirculation before and after therapy in patients with newly diagnosed multiple myeloma with dynamic contrast-enhanced MRI (DCE-MRI).

EXPERIMENTAL DESIGN

Ninety-six patients received DCE-MRI before and after primary treatment for newly diagnosed multiple myeloma. For the 91 evaluable patients, treatment consisted of high-dose therapy (HDT) with autologous stem cell transplantation (ASCT) in 82 patients and chemotherapy without ASCT in 9 patients. In addition, 33 healthy volunteers were imaged as the control group. Analysis of DCE-MRI was performed according to the two-compartment model by Brix to quantify amplitude A (associated with blood volume) and exchange rate constant kep (reflecting vessel permeability and perfusion).

RESULTS

Nonresponders showed significantly higher A-values before the start of therapy compared with responders (P = 0.02). In both responders and nonresponders to therapy, A-values dropped significantly (P = 0.004 and <0.001, respectively) after primary therapy, whereas lower values for kep were found only in responders (P < 0.001). Depth of remission was significantly correlated to decreased bone marrow microcirculation: Patients in near complete response (nCR) or complete remission (CR) after treatment showed significantly lower values for A compared with patients not achieving nCR+CR. The application of HDT or novel agents had no significant effect on DCE-MRI parameters after therapy, although patients treated with novel agents more often achieved nCR+CR (42%/12.5%; P < 0.002). Higher kep-values at second MRI were positively correlated to shorter overall survival (HR 3.53; 95% confidence intervals, 1.21-10.33; P = 0.02).

CONCLUSION

Parameters from DCE-MRI are correlated to remission after primary therapy and outcome in newly diagnosed multiple myeloma.

Multiple mechanisms contribute to the synergistic anti-myeloma activity of the pan-histone deacetylase inhibitor LBH589 and the rapalog RAD001

We examined the pre-clinical activity of pan-histone deacetylase inhibitor LBH589 in combination with mTORC1 inhibitor RAD001 and observed that the drug combination strongly synergized in inducing cytotoxicity in multiple myeloma (MM) cells. LBH589 caused an increase in acetylated histones and RAD001 inhibited mTORC1 activity. RAD001 caused potent G0/G1 arrest while LBH589 induced pronounced apoptosis, both of which were enhanced when the drugs were used in combination. LBH589/RAD001 combination led to down regulation of pStat3, cyclins, CDKs and XIAP and up regulation of pro-apoptotic Bcl-2 family proteins. A clinical trial is underway using LBH589/RAD001 combination in relapsed MM patients.

Immunological dysregulation in multiple myeloma microenvironment

Multiple Myeloma (MM) is a systemic hematologic disease due to uncontrolled proliferation of monoclonal plasma cells (PC) in bone marrow (BM). Emerging in other solid and liquid cancers, the host immune system and the microenvironment have a pivotal role for PC growth, proliferation, survival, migration, and resistance to drugs and are responsible for some clinical manifestations of MM. In MM, microenvironment is represented by the cellular component of a normal bone marrow together with extracellular matrix proteins, adhesion molecules, cytokines, and growth factors produced by both stromal cells and PC themselves. All these components are able to protect PC from cytotoxic effect of chemo- and radiotherapy. This review is focused on the role of immunome to sustain MM progression, the emerging role of myeloid derived suppressor cells, and their potential clinical implications as novel therapeutic target.

Bone marrow microenvironment in multiple myeloma progression

Substantial advances have been made in understanding the biology of multiple myeloma (MM) through the study of the bone marrow (BM) microenvironment. Indeed, the BM niche appears to play an important role in differentiation, migration, proliferation, survival, and drug resistance of the malignant plasma cells. The BM niche is composed of a cellular compartment (stromal cells, osteoblasts, osteoclasts, endothelial cells, and immune cells) and a noncellular compartment including the extracellular matrix (ECM) and the liquid milieu (cytokines, growth factors, and chemokines). In this paper we discuss how the interaction between the malignant plasma cell and the BM microenvironment allowed myeloma progression through cell homing and the new concept of premetastatic niche.

Assessment of bone marrow fibrosis and angiogenesis in monitoring patients with multiple myeloma

The aim of our study was to emphasize the importance of accurate and standardized techniques for detailed monitoring of the microenvironment in multiple myeloma (MM). Bone marrow fibrosis, angiogenesis, and plasma cell infiltrates in bone marrow biopsy (BMB) samples at the time of diagnosis and on completion of therapy were analyzed for 42 patients with newly diagnosed MM. Computerized image analysis was used for all slides stained with anti-CD138 and anti-CD34. The patients with fibrosis in pretreatment BMB samples had significantly higher microvessel density (MVD) and plasma cell infiltrates. In posttreatment BMB samples, nonresponders had a significantly higher frequency and grade of fibrosis and higher values of MVD, total vascular area, and plasma cell percentage. The overall survival of nonresponders and patients with increased marrow fibrosis in posttreatment BMB samples was significantly shorter. The obtained results confirm that complex morphologic examination of the bone marrow microenvironment during the monitoring of MM can provide better prognostic significance.

Angioimmunoblastic T-cell lymphoma: the effect of initial treatment and microvascular density in 31 patients

The objectives of this study are to explore the clinical features and treatment outcomes and to investigate the correlation between microvessel density (MVD) and survival in patients with angioimmunoblastic T-cell lymphoma (AITL). We retrospectively analyzed clinical and follow-up data of 31 patients treated in two hospitals during 1995-2009 histologically proven AITL. We also assessed MVD in the lump of 31 previously untreated patients using α-CD34 immunohistochemical staining. The median age of the 31 patients was 48 years, eighty percent of the patients were in an advanced stage. 67.7% of them had B symptoms, with the follow-up of 2-13 years, the 5-year overall survival rate was 25.8%. The response rates (RR) of CHOP group and COP (cyclophosphamide, vincristine and prednisolone) group are 76.5 and 75%, respectively, which is no significant difference (P=0.894). RR did not differ whether chemotherapy regimens contained anthracycline or not. The 3-year PFS rate for patients who received COP and CHOP regimen was 25.4 and 35.3% (P=0.562), while 5-year OS rates were 25.0 and 29.4%, respectively (P=0.667). The median PFS for patients with high MVD and low MVD were 15.1 and 30.0 months (P=0.048), while the median OS were 20 and 45 months, respectively (P=0.038). Patients who were sensitive to initial chemotherapy COP regimen have the similar therapeutic effect to CHOP regimen. Patients with high MVD measured in the microenvironment had worse PFS and OS than AITL patients with low expression.

Angiogenesis and multiple myeloma

The bone marrow microenvironment in multiple myeloma is characterized by an increased microvessel density. The production of pro-angiogenic molecules is increased and the production of angiogenic inhibitors is suppressed, leading to an "angiogenic switch". Here we present an overview of the role of angiogenesis in multiple myeloma, the pro-angiogenic factors produced by myeloma cells and the microenvironment, and the mechanisms involved in the myeloma-induced angiogenic switch. Current data suggest that the increased bone marrow angiogenesis in multiple myeloma is due to the aberrant expression of angiogenic factors by myeloma cells, the subsequent increase in pro-angiogenic activity of normal plasma cells as a result of myeloma cell angiogenic activity, and the increased number of plasma cells overall. Hypoxia also contributes to the angiogenic properties of the myeloma marrow microenvironment. The transcription factor hypoxia-inducible factor-1α is overexpressed by myeloma cells and affects their transcriptional and angiogenic profiles. In addition, potential roles of the tumor suppressor gene inhibitor of growth family member 4 and homeobox B7 have also been recently highlighted as repressors of angiogenesis and pro-angiogenic related genes, respectively. This complex pathogenetic model of myeloma-induced angiogenesis suggests that several pro-angiogenic molecules and related genes in myeloma cells and the microenvironment are potential therapeutic targets.

Prognostic value of bone marrow microvessel density and angiogenic cytokines in patients with multiple myeloma undergoing autologous stem cell transplant

Angiogenesis is important for the proliferation and metastasis of most malignant neoplasms including multiple myeloma (MM). The aim of this study was to evaluate the role of bone marrow angiogenesis and angiogenic cytokines in patients with MM prior to and after autologous stem cell transplant (ASCT). Twenty-nine patients with MM who underwent ASCT had serial samples of serum and bone marrow biopsies at diagnosis, prior to ASCT, and at the 3rd and 6th months post-transplant. Besides bone marrow microvessel density (MVD), serum angiogenic cytokines including vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF) and markers of disease activity such as interleukin-6 (IL-6), IL-1β, C-reactive protein (CRP), β(2)-microglobulin, and bone marrow plasma cells (BMPCs) were also determined. Bone marrow MVD, serum levels of IL-6, CRP, and β(2)-microglobulin, and BMPCs decreased significantly from diagnosis to the 6th month post-transplant (p < 0.05). Serum FGF and IL-1β levels decreased significantly until 3 months post-transplant, however lost this significance at the 6th month. Serum VEGF levels did not vary significantly during follow-up. MVD, serum angiogenic cytokine levels, and parameters reflecting disease activity were similar in responders and non-responders to induction chemotherapy. Cytokines and MVD both at diagnosis and prior to transplant did not show any correlation with overall survival (OS) and progression-free survival (PFS) after a median follow-up of 55 months after transplant (p > 0.05). Our findings suggest that bone marrow MVD decreases significantly with ASCT in MM, however without an impact on OS and PFS.

JS-K has potent anti-angiogenic activity in vitro and inhibits tumour angiogenesis in a multiple myeloma model in vivo

OBJECTIVES

Glutathione S-transferases (GSTs) play an important role in multidrug resistance and are upregulated in multiple cancers. We have designed a prodrug class that releases nitric oxide on metabolism by GST. O(2)-(2,4-Dinitrophenyl) 1-[(4-ethoxycarbonyl)piperazin-1-yl]diazen-1-ium-1,2-diolate (JS-K, a member of this class) has potent antineoplastic activity.

METHODS

We studied the effect of JS-K on angiogenesis in human umbilical vein endothelial cells (HUVECs), OPM1 multiple myeloma cells, chick aortic rings and in mice.

KEY FINDINGS

JS-K inhibited the proliferation of HUVECs with a 50% inhibitory concentration (IC50) of 0.432, 0.466 and 0.505 microm at 24, 48 and 72 h, respectively. In the cord formation assay, JS-K led to a decrease in the number of cord junctions and cord length with an IC50 of 0.637 and 0.696 microm, respectively. JS-K inhibited cell migration at 5 h using VEGF as a chemoattractant. Migration inhibition occurred with an IC50 of 0.493 microm. In the chick aortic ring assay using VEGF or FGF-2 for vessel growth stimulation, 0.5 microm JS-K completely inhibited vessel growth. JS-K inhibited tumour angiogenesis in vivo in NIH III mice implanted subcutaneously with OPM1 multiple myeloma cells.

CONCLUSIONS

JS-K is a potent inhibitor of angiogenesis in vitro and tumour vessel growth in vivo. As such, it establishes a new class of antineoplastic agent that targets the malignant cells directly as well as their microenvironment.

[Whole body functional MR imaging: hemato-oncologic applications]

Hemato-oncologic imaging combines anatomical and functional imaging data for optimal staging and follow-up of patients. It is currently possible to achieve high spatial resolution and functional evaluation at whole body MR imaging. Functional imaging may be achieved with two techniques: dynamic imaging following intravenous contrast injection and diffusion-weighted imaging. The purpose of this article is to demonstrate how both functional imaging techniques can be combined with whole body MR imaging for the evaluation of multiple myeloma and lymphomas.

Sorafenib, a dual Raf kinase/vascular endothelial growth factor receptor inhibitor has significant anti-myeloma activity and synergizes with common anti-myeloma drugs

Multiple myeloma is characterized by increased bone marrow neovascularization driven in part by vascular endothelial growth factor (VEGF). In addition, the Ras/Raf/MEK/ERK pathway is critical for the proliferation of myeloma cells and is often upregulated. Sorafenib (Nexavar) is a novel multi-kinase inhibitor that acts predominantly through inhibition of Raf-kinase and VEGF receptor 2, offering the potential for targeting two important aspects of disease biology. In in vitro studies, sorafenib-induced cytotoxicity in MM cell lines as well as freshly isolated patient myeloma cells. It retained its activity against MM cells in co-culture with stromal cells or with interleukin-6, VEGF or IGF; conditions mimicking tumor microenvironment. Examination of cellular signaling pathways showed downregulation of Mcl1 as well as decreased phosphorylation of the STAT3 and MEK/ERK, as potential mechanisms of its anti-tumor effect. Sorafenib induces reciprocal upregulation of Akt phosphorylation; and simultaneous inhibition of downstream mTOR with rapamycin leads to synergistic effects. Sorafenib also synergizes with drugs such as proteasome inhibitors and steroids. In a human in vitro angiogenesis assay, sorafenib showed potent anti-angiogenic activity. Sorafenib, through multiple mechanisms exerts potent anti-myeloma activity and these results favor further clinical evaluation and development of novel sorafenib combinations.

The molecular characterization and clinical management of multiple myeloma in the post-genome era

Cancer-causing mutations disrupt coordinated, precise programs of gene expression that govern cell growth and differentiation. Microarray-based gene-expression profiling (GEP) is a powerful tool to globally analyze these changes to study cancer biology and clinical behavior. Despite overwhelming genomic chaos in multiple myeloma (MM), expression patterns within tumor samples are remarkably stable and reproducible. Unique expression patterns associated with recurrent chromosomal translocations and ploidy changes defined molecular classes with differing clinical features and outcomes. Combined molecular techniques also dissected two distinct, reproducible forms of hyperdiploid disease and have molecularly defined MM with high risk for poor clinical outcome. GEP is now used to risk-stratify patients with newly diagnosed MM. Groups with high-risk features are evident in all GEP-defined MM classes, and GEP studies of serial samples showed that risk increases over time, with relapsed disease showing dramatic GEP shifts toward a signature of poor outcomes. This suggests a common mechanism of disease evolution and potentially reflects preferential expansion of therapy-resistant cells. Correlating GEP-defined disease class and risk with outcomes of therapeutic regimens reveals class-specific benefits for individual agents, as well as mechanistic insights into drug sensitivity and resistance. Here, we review modern genomics contributions to understanding MM pathogenesis, prognosis, and therapy.

Patients with plasma cell disorders examined at whole-body dynamic contrast-enhanced MR imaging: initial experience

This study was approved by the institutional review board, and informed consent was obtained from all subjects. The authors prospectively evaluated the feasibility of multistation whole-body dynamic contrast material-enhanced magnetic resonance (MR) imaging performed in patients with plasma cell disorders to assess disease extension and the time-signal intensity curves of diffuse and focal bone marrow infiltration. Three healthy adult male volunteers (age range, 29-31 years) and 21 patients (12 men, nine women; age range, 34-79 years) underwent whole-body dynamic unenhanced (volunteers) and contrast-enhanced MR imaging, which was performed by using an 18-channel 1.5-T MR system. A five-station (three sagittal and two coronal planes) fat-saturated three-dimensional gradient-echo sequence (3.3-3.6/1.3 [repetition time msec/echo time msec], 20 degrees flip angle, voxel size of 2 x 2.6 x [3-5] mm) was performed seven times. The temporal resolution of the five-station dynamic contrast-enhanced examination was 60 seconds with use of parallel imaging. Time-signal intensity curves for the bone marrow and the focal lesions were successfully obtained in all patients.

SUPPLEMENTAL MATERIAL

http://radiology.rsnajnls.org/cgi/content/full/250/3/905/DC1http://radiology.rsnajnls.org/cgi/content/full/250/3/905/DC2http://radiology.rsnajnls.org/cgi/content/full/250/3/905/DC3.

Increased bone marrow microvascular density in haematological malignancies is associated with differential regulation of angiogenic factors

Antiangiogenic drugs are currently tested in haematological malignancies. As these drugs target different angiogenic regulators, and as cancers are inherently heterogeneous, a detailed characterization of angiogenesis in individual cancers is needed. Hence, we measured bone marrow microvessel density (MVD), plasma concentrations of eight angiogenesis-related parameters and the expression in blood mononuclear cells of 40 angiogenesis-related mRNAs in 93 patients with haematological neoplasias (acute myeloid leukaemia; chronic lymphatic leukaemia; multiple myeloma (MM); or non-Hodgkin's lymphoma (NHL)) before start and after completion of cancer therapy. Compared with healthy individuals, the patients had significantly increased bone marrow MVD, especially patients with advanced stage disease. A novel finding was that patients with NHL also had increased bone marrow MVD. The plasma levels of vascular endothelial growth factor (VEGF), interleukin (IL)-6 and IL-8 were significantly increased. VEGF levels were highest in those who did not achieve complete remission after cancer therapy. The mRNA expression of IL-8 was upregulated 15-fold. Our data show that patients with haematological malignancies have increased bone marrow MVD; hence, supporting the notion that bone marrow angiogenesis plays a role in the pathogenesis and progression of these cancers. VEGF, IL-6 and IL-8 seem to contribute to the malignant phenotype.

Bone marrow angiogenesis and angiogenic factors in multiple myeloma treated with novel agents

INTRODUCTION

An increased bone marrow (BM) angiogenesis is associated with poor outcome in multiple myeloma (MM).

OBJECTIVE

Angiogenesis study in MM treated with novel antimyeloma agents: thalidomide, lenalidomide, bortezomib, and with dexamethasone.

PATIENTS AND METHODS

Forty-four patients with MM (14 newly diagnosed, 30 refractory/relapsed) were treated with novel agents at our institution. A BM biopsy was obtained before the initiation of therapy in 19. Angiogenesis was assessed by microvessel density (MVD) estimation in BM biopsies stained with the monoclonal anti-CD34 antibody, and by serum levels of angiogenic factors (VEGF, bFGF, and HGF) and cytokines (IL-6 and TNF-alpha).

RESULTS

A positive correlation was found between BM plasma cell involvement and MVD estimation (p=0.01). However, MVD was not significantly correlated with either disease phase (p=0.065) or response to therapy (p=0.79). Neither baseline serum levels of angiogenic cytokines correlated to response to treatment. No significant correlation was found between BM MVD and serum levels of angiogenic cytokines. Serum levels of angiogenic cytokines before and after therapy showed a significant increase of bFGF (p=0.008).

CONCLUSION

There is no relationship between MVD estimation and baseline serum levels of angiogenic cytokines, neither between each of them and response to therapy.

Prognostic significance of VEGF, VEGF receptors, and microvessel density in diffuse large B cell lymphoma treated with anthracycline-based chemotherapy

Vascular endothelial growth factor-mediated signaling has at least two potential roles in diffuse large B cell lymphoma: potentiation of angiogenesis, and potentiation of lymphoma cell proliferation and/or survival induced by autocrine vascular endothelial growth factor receptor-mediated signaling. We have recently shown that diffuse large B cell lymphomas expressing high levels of vascular endothelial growth factor protein also express high levels of vascular endothelial growth factor receptor-1 and vascular endothelial growth factor receptor-2. We have now assessed a larger multi-institutional cohort of patients with de novo diffuse large B cell lymphoma treated with anthracycline-based therapy to address whether tumor vascularity, or expression of vascular endothelial growth factor protein and its receptors, contribute to patient outcomes. Our results show that increased tumor vascularity is associated with poor overall survival (P=0.047), and is independent of the international prognostic index. High expression of vascular endothelial growth factor receptor-1 by lymphoma cells by contrast is associated with improved overall survival (P=0.044). The combination of high vascular endothelial growth factor and vascular endothelial growth factor receptor-1 protein expression by lymphoma cells identifies a subgroup of patients with improved overall (P=0.003) and progression-free (P=0.026) survival; these findings are also independent of the international prognostic index. The prognostic significance of overexpression of this ligand-receptor pair suggests that autocrine signaling via vascular endothelial growth factor receptor-1 may represent a survival or proliferation pathway in diffuse large B cell lymphoma. Dependence on autocrine vascular endothelial growth factor receptor-1-mediated signaling may render a subset of diffuse large B-cell lymphomas susceptible to anthracycline-based therapy.

Extravasation and homing mechanisms in multiple myeloma

Multiple myeloma (MM) is a malignant B-cell disorder characterized by a monoclonal expansion of plasma cells (PC) in the bone marrow (BM). During the main course of disease evolution, MM cells depend on the BM microenvironment for their growth and survival. Reciprocal interactions between MM cells and the BM mediate not only MM cell growth, but also protect them against apoptosis and cause bone disease and angiogenesis. A striking feature of MM represents the predominant localization and retention of MM cells in the BM. Although BM PC indeed represent the main neoplastic cell type, small numbers of MM cells can also be detected in the peripheral blood circulation. It can be assumed that these circulating cells represent the tumour-spreading component of the disease. This implicates that MM cells have the capacity to (re)circulate, to extravasate and to migrate to the BM (homing). In analogy to the migration and homing of normal leucocytes, the BM homing of MM cells is mediated by a multistep process of extravasation with adhesion to the endothelium, invasion of the subendothelial basement membrane, followed by further migration within the stroma, mediated by chemotactic factors. At the end stage of disease, MM cells are thought to develop autocrine growth supporting loops that enable them to survive and proliferate in the absence of the BM microenvironment and to become stroma-independent. In this stage, the number of circulating cells increases and growth at extramedullary sites can occur, associated with alteration in adhesion molecule and chemokine receptor expression. This review summarizes the recent progress in the study of the extravasation and homing mechanisms of MM cells.

Microvessel density and expression of vascular endothelial growth factor and its receptors in diffuse large B-cell lymphoma subtypes

Angiogenesis is known to play a major role in neoplasia, including hematolymphoid neoplasia. We assessed the relationships among angiogenesis and expression of vascular endothelial growth factor and its receptors in the context of clinically and biologically relevant subtypes of diffuse large B-cell lymphoma using immunohistochemical evaluation of tissue microarrays. We found that diffuse large B-cell lymphoma specimens showing higher local vascular endothelial growth factor expression showed correspondingly higher microvessel density, implying that lymphoma cells induce local tumor angiogenesis. In addition, local vascular endothelial growth factor expression was higher in those specimens showing higher expression of the receptors of the growth factor, suggesting an autocrine growth-promoting feedback loop. The germinal center-like and nongerminal center-like subtypes of diffuse large B-cell lymphoma were biologically and prognostically distinct. Interestingly, only in the more clinically aggressive nongerminal center-like subtype were microvessel densities significantly higher in specimens showing higher vascular endothelial growth factor expression; the same was true for the finding of higher vascular endothelial growth factor receptor-1 expression in conjunction with higher vascular endothelial growth factor expression. These differences may have important implications for the responsiveness of the two diffuse large B-cell lymphoma subtypes to anti-vascular endothelial growth factor and anti-angiogenic therapies.

New staging systems can predict prognosis of multiple myeloma patients undergoing autologous peripheral blood stem cell transplantation as first-line therapy

Staging systems for multiple myeloma (MM) include the Southwest Oncology Group (SWOG) staging system, the International Staging System (ISS), and the Durie-Salmon (DS) staging system. We evaluated whether staging at the time of diagnosis could predict survival in MM patients undergoing autologous peripheral blood stem cell transplantation (APBSCT) as first-line treatment. Between November 1996 and June 2005, 152 MM patients were treated with induction VAD (vincristine, adriamycin, dexamethasone) chemotherapy, followed by APBSCT at 6 institutions in Korea. Median follow-up times were 22.6 months (range, 5.4-101.9 months) from the day of diagnosis and 14.1 months (range, 0.4-96.1 months) from the day of APBSCT. Progression-free survival (PFS) from the day of diagnosis was predicted by the SWOG staging system (P = .0129) and ISS (P = .0299), but not by the DS staging system at diagnosis (P = .1074). In addition, overall survival (OS) from the day of diagnosis could be predicted by the SWOG staging system (P = .0207) and ISS (P = .0105), but not by the DS staging system (P = .2542). PFS from day of APBSCT was not predicted by the DS staging system (P = .5731), SWOG staging system (P = .2817), or ISS (P = .1167). OS from day of APBSCT could be predicted by the SWOG staging system (P = .0392) and ISS (P = .0198), but not by the DS staging system (P = .5426). Our findings indicate that PFS and OS in association with APBSCT can be predicted by stages assessed by the SWOG and ISS systems, but not by the DS system. Moreover, staging by the SWOG and ISS systems at the time of diagnosis was better correlated with survival than was staging at the time of APBSCT.